Question

A nurse is planning to delegate client assignments to an assistive personnel. Which of the following tasks is appropriate for the nurse to delegate?

Answer 1

Correct Answers:

Collecting a urine specimen

Rationale :

⏺️Collecting a urine specimen is a basic, non-invasive procedure that falls within the scope of assistive personnel (AP).

⏺️This task does not require assessment, interpretation, or decision-making, making it safe for delegation.

⏺️APs are trained to follow infection control protocols when collecting specimens, ensuring safety.

⏺️ Delegating such routine tasks allows the nurse to focus on complex assessments and interventions.

⏺️The nurse remains responsible for verifying the accuracy of labeling and documentation after collection.

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Answer 2

Correct Answers:

Sit with a client who has anorexia nervosa during meals.

Rationale :

🟣Sitting with the client provides behavioral reinforcement and encouragement to eat, which is crucial in anorexia nervosa management.

🟣This task does not involve assessment or interpretation, making it appropriate for assistive personnel.

🟣Close monitoring during meals reduces the risk of food hiding or purging behaviors in clients with eating disorders.

🟣APs are trained to provide emotional support and supervision, which enhances client compliance with the care plan.

🟣The nurse remains responsible for monitoring intake records and overall progress.

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Answer 3

Correct Answers

Blank 1 Correct Option: Compartment syndrome
Blank 2 Correct Option: Remove pillow elevating right lower extremity and Loosen Surgical Dressings
Blank 3 Correct Option: Capillary refill and Increasing pain level

Rationale :

Potential Condition: Compartment Syndrome

✅ The client’s severe pain (9/10), numbness and tingling, cool, hard skin, and diminished pedal pulse (+1) are classic signs of compartment syndrome, which results from increased pressure within a confined muscle compartment.

✅ Rising compartmental pressure compromises circulation and nerve function, causing ischemia and potential tissue necrosis if untreated.

✅ Postoperative patients with fractures, casts, or tight dressings are at high risk due to bleeding, edema, or external compression within the compartment.

✅ Compartment syndrome is a surgical emergency; delayed recognition can lead to permanent nerve damage, muscle contractures, or limb loss.

✅ Early recognition and prompt intervention can prevent progression to irreversible tissue damage.

Actions to Take

Remove pillow elevating right lower extremity

✅Keeping the limb at heart level enhances arterial blood flow, while elevation worsens arterial perfusion.

✅ Adequate arterial flow is essential to restore oxygen and nutrient delivery to the affected tissues.

✅ Reducing elevation decreases compartmental pressure, promoting venous return without compromising arterial flow.

✅ Avoiding further elevation limits additional circulatory compromise.

✅Removing elevation is a standard first-line nursing action in suspected compartment syndrome.

Loosen Surgical Dressings

✅ Tight dressings increase tissue pressure, worsening ischemia; loosening them relieves external pressure.

✅ Reducing compression improves capillary perfusion to the affected tissues.

✅This is a critical initial intervention while awaiting further medical or surgical evaluation.

✅Loosening dressings reduces the risk of permanent tissue damage before fasciotomy is considered.

✅ Reduced pressure also helps relieve pain caused by nerve compression.

Parameters to Monitor

Increasing Pain Level

✅ Unrelieved or disproportionate pain, even after analgesics, is a hallmark of worsening compartment syndrome.

✅ Severe pain occurs due to nerve compression and reduced blood flow.

✅Monitoring pain trends helps identify deteriorating circulation.

✅ Escalating pain signals the need for immediate surgical consultation.

✅Pain is considered the most sensitive early indicator of compartment syndrome.

Capillary Refill

✅Delayed capillary refill (>2 seconds) indicates poor tissue perfusion.

✅ Frequent monitoring can detect circulatory compromise early.

✅ Worsening capillary refill time shows progressing ischemia.

✅Unlike subjective symptoms, it provides a quick, measurable parameter.

✅Abnormal findings warrant immediate escalation of care.

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Answer 4

Correct Answers:

A client who has difficulty swallowing.

Rationale :

🟢 Difficulty swallowing (dysphagia) requires evaluation and intervention by a speech-language pathologist (SLP), as they specialize in assessing swallowing and communication disorders.

🟢 The SLP can perform a swallowing assessment to determine the risk of aspiration and recommend safe swallowing techniques.

🟢 Clients with dysphagia may need modified food textures and thickened liquids, which are guided by the SLP to prevent aspiration pneumonia.

🟢 The SLP can also provide therapeutic exercises to strengthen the muscles involved in swallowing, improving nutritional intake and airway protection.

🟢 Early referral to an SLP helps in preventing complications such as malnutrition, dehydration, and respiratory infections caused by aspiration.

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Answer 5

Correct Answers:

Social worker.

Rationale :

🔵 A social worker is the appropriate interdisciplinary team member for arranging family therapy because they are trained in counseling and psychosocial interventions.

🔵 Social workers help address family dynamics, coping mechanisms, and interpersonal conflicts, which are key in family therapy.

🔵 They can also connect families with community resources and support groups to improve psychosocial well-being.

🔵 Their role includes providing education to help families better understand the client’s mental or physical health condition.

🔵 Early involvement of a social worker can reduce family stress, improve communication, and enhance treatment compliance.

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Answer 6

Correct Answers:

Hepatosplenomegaly

Rationale :

🟡 Right ventricular heart failure leads to systemic venous congestion, causing blood to back up into the liver and spleen.

🟡 Hepatosplenomegaly is an expected finding due to increased venous pressure causing liver and spleen enlargement.

🟡 The liver becomes engorged, which may also lead to ascites and jaundice in severe cases.

🟡 Other systemic signs include peripheral edema, jugular vein distention, and weight gain caused by fluid retention.

🟡 Identifying hepatosplenomegaly helps in assessing the severity of right-sided heart failure and guiding treatment such as diuretics to reduce congestion.

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Answer 7

Correct Answers:

Pertussis

Rationale :

🟣 Pertussis (whooping cough) spreads through respiratory droplets, requiring droplet precautions to prevent transmission.

🟣 The nurse should wear a mask within 3 feet of the client and ensure the client wears a mask if transported.

🟣 Droplet precautions prevent the spread of respiratory secretions containing Bordetella pertussis.

🟣 The illness causes severe coughing fits, increasing the risk of spreading droplets through coughing and sneezing.

🟣 Maintaining droplet precautions protects other vulnerable patients, especially infants, from severe respiratory complications.

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Answer 8

Correct Answers:

Realign the extremity in traction.

Rationale :

🔴 Muscle spasms in skeletal traction are often caused by misalignment of the extremity.

🔴 Proper realignment of the bone and soft tissues restores correct traction pull, reducing pain and muscle tension.

🔴 The nurse should not remove weights but instead ensure the weights are hanging freely and not touching the floor.

🔴 Correct alignment maintains immobilization, bone healing, and proper muscle relaxation.

🔴 Frequent assessment and realignment of traction also prevent complications such as pressure ulcers, nerve damage, and circulatory impairment.

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Answer 9

Correct Answers:

Hepatitis C

Rationale :

⚫ Atorvastatin, a lipid-lowering statin, is metabolized in the liver and is contraindicated in clients with active liver disease such as hepatitis C.

⚫ Liver dysfunction increases the risk of drug-induced hepatotoxicity, which can worsen liver damage.

⚫ Baseline and ongoing liver function tests (LFTs) are required before initiating statins.

⚫ Using statins in clients with hepatitis can lead to elevated liver enzymes and possible liver failure.

⚫ Alternative lipid-lowering therapies should be considered for clients with active hepatic disease.

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Answer 10

Correct Answers:

Improve joint functioning.

Rationale :

🟢 Chondroitin and glucosamine are dietary supplements used to support joint health and manage osteoarthritis symptoms.

🟢 They help in cartilage repair and maintenance, reducing joint stiffness and pain.

🟢 Glucosamine is involved in the production of synovial fluid and joint cartilage, improving mobility.

🟢 Chondroitin sulfate inhibits enzymes that break down cartilage, thus slowing degenerative changes.

🟢 Regular use can enhance joint functioning and reduce the need for NSAIDs in mild to moderate osteoarthritis.

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QLexNursing

1 :
A nurse is planning to delegate client assignments to an assistive personnel. Which of the following tasks is appropriate for the nurse to delegate?

2 :
A nurse is caring for a group of clients in an inpatient mental health facility. Which of the following tasks should the nurse delegate to an assistive personnel?

3 :
A nurse is caring for a client who is postoperative.

Correct Answers

4 :
A nurse is caring for a group of clients. The nurse should request a referral for a speech language pathologist for which of the following clients?

5 :
A community health nurse is caring for a client who requests a referral for family therapy. The nurse should initiate a referral to which of the following members of the interdisciplinary team?

6 :
A nurse is reviewing the history and physical of a client who has right ventricular heart failure. Which of the following is an expected finding?

7 :
A nurse in a pediatric unit is caring for a group of clients. For which of the following diseases should the nurse implement droplet precautions?

8 :
A nurse is caring for a client who has a left femur fracture and is in skeletal traction. The client reports pain due to muscle spasms in the affected leg. Which of the following is an appropriate action by the nurse?

9 :
A nurse is caring for a client who has a prescription for atorvastatin. Which of the following client conditions is a contraindication to this medication?

10 :
A nurse is caring for a client who reports the use of chondroitin and glucosamine. The health benefit of this supplement combination is to do which of the following?

QLexNursing

1 : A nurse is planning to delegate client assignments to an assistive personnel. Which of the following tasks is appropriate for the nurse to delegate?

2 : A nurse is caring for a group of clients in an inpatient mental health facility. Which of the following tasks should the nurse delegate to an assistive personnel?

3 : A nurse is caring for a client who is postoperative.

Correct Answers

4 : A nurse is caring for a group of clients. The nurse should request a referral for a speech language pathologist for which of the following clients?

5 : A community health nurse is caring for a client who requests a referral for family therapy. The nurse should initiate a referral to which of the following members of the interdisciplinary team?

6 : A nurse is reviewing the history and physical of a client who has right ventricular heart failure. Which of the following is an expected finding?

7 : A nurse in a pediatric unit is caring for a group of clients. For which of the following diseases should the nurse implement droplet precautions?

8 : A nurse is caring for a client who has a left femur fracture and is in skeletal traction. The client reports pain due to muscle spasms in the affected leg. Which of the following is an appropriate action by the nurse?

9 : A nurse is caring for a client who has a prescription for atorvastatin. Which of the following client conditions is a contraindication to this medication?

10 : A nurse is caring for a client who reports the use of chondroitin and glucosamine. The health benefit of this supplement combination is to do which of the following?

1 :
A nurse is planning to delegate client assignments to an assistive personnel. Which of the following tasks is appropriate for the nurse to delegate?

2 :
A nurse is caring for a group of clients in an inpatient mental health facility. Which of the following tasks should the nurse delegate to an assistive personnel?

3 :
A nurse is caring for a client who is postoperative.

4 :
A nurse is caring for a group of clients. The nurse should request a referral for a speech language pathologist for which of the following clients?

5 :
A community health nurse is caring for a client who requests a referral for family therapy. The nurse should initiate a referral to which of the following members of the interdisciplinary team?

6 :
A nurse is reviewing the history and physical of a client who has right ventricular heart failure. Which of the following is an expected finding?

7 :
A nurse in a pediatric unit is caring for a group of clients. For which of the following diseases should the nurse implement droplet precautions?

8 :
A nurse is caring for a client who has a left femur fracture and is in skeletal traction. The client reports pain due to muscle spasms in the affected leg. Which of the following is an appropriate action by the nurse?

9 :
A nurse is caring for a client who has a prescription for atorvastatin. Which of the following client conditions is a contraindication to this medication?

10 :
A nurse is caring for a client who reports the use of chondroitin and glucosamine. The health benefit of this supplement combination is to do which of the following?