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 appropriate to delegate to assistive personnel because it is a routine, standard task that does not require nursing judgment or interpretation.

🔷 Delegation is appropriate when the task is predictable, has a low risk of harm, and does not involve assessment, teaching, or evaluation.

🔷 A urine specimen can be collected by assistive personnel and then reported to the nurse for follow-up as needed.

🔷 The nurse remains responsible for interpreting the results and deciding whether further intervention is necessary.

🔷 For this reason, collecting a urine specimen is the best task to delegate.

Measuring a client's pain level

🔷 Pain level is considered part of client assessment, and assessment data require nursing judgment.

🔷 Because the nurse must analyze the pain finding and determine the appropriate response, this task should not be delegated to assistive personnel.

Monitoring blood glucose levels

🔷 Blood glucose monitoring is not the best answer for assistive personnel in this question because it is commonly identified in nursing scope documents as a task performed by licensed nursing personnel such as an LPN/VN, not the simplest UAP delegation choice here.

🔷 The safest clearly appropriate delegated task from the options is urine specimen collection, which does not involve direct interpretation of potentially unstable metabolic findings.

Adjusting the flow rate of a client's oxygen tank

🔷 Adjusting oxygen flow rate involves changing a treatment and requires clinical judgment and provider-prescribed parameters.

🔷 This is not an appropriate task to delegate to assistive personnel because incorrect oxygen adjustment can harm the client.

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Answer 2

Correct Answers:

Sit with a client who has anorexia nervosa during meals.

Rationale :

🔶 Sitting with a client who has anorexia nervosa during meals is an appropriate task for assistive personnel because it is a supportive, routine observation role.

🔶 This task helps reinforce meal supervision and safety without requiring independent nursing assessment or legal responsibility.

🔶 The nurse can delegate the observation component while remaining responsible for evaluating intake, behavior, and clinical response.

🔶 In mental health settings, assistive personnel are often appropriate for structured, predictable support activities.

🔶 For this reason, sitting with a client who has anorexia nervosa during meals is the best task to delegate.

Obtain the vital signs of a client who has experienced a seizure

🔶 A client who has experienced a seizure may be unstable and requires nursing assessment and judgment about complications and neurologic status.

🔶 Because of the potential for rapid changes in condition, this task should not be delegated as the best option in this situation.

Witness a client's signature on an informed consent document

🔶 Witnessing informed consent is not a task for assistive personnel because it involves legal and ethical responsibilities tied to confirming the client’s voluntary signature and readiness.

🔶 This responsibility should be handled according to facility policy by appropriate licensed personnel.

Complete an incident report following a client fall

🔶 Completing an incident report is not delegated to assistive personnel because it requires documentation by licensed staff involved in the event and follow-up through the nursing process.

🔶 The nurse is responsible for assessment, documentation, and reporting after a client fall.

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Answer 3

Correct Answers

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

Rationale :

Compartment syndrome

🔷 The client is most likely experiencing compartment syndrome because the findings show numbness and tingling, severe pain 9/10, decreased right pedal pulse, cool skin, and a hard swollen extremity.

🔷 Compartment syndrome occurs when pressure builds up within a closed muscle compartment and begins to impair circulation and nerve function.

🔷 One of the earliest and most important signs is pain that becomes severe and is out of proportion to the expected postoperative course.

🔷 The progression from a stable assessment at 0700 to worsening neurovascular findings at 1700 strongly supports acute compartment syndrome rather than a routine postoperative change.

🔷 For these reasons, compartment syndrome is the condition the nurse should recognize immediately.

Osteomyelitis

🔷 Osteomyelitis is a bone infection and usually develops with findings such as fever, elevated WBC count, and localized infection signs rather than sudden neurovascular compromise.

🔷 This client’s most urgent findings are hard cool skin, severe pain, tingling, and reduced pulse, which fit compartment syndrome more closely.

Cellulitis

🔷 Cellulitis usually causes redness, warmth, tenderness, and swelling from a soft tissue infection.

🔷 This client’s extremity is cool, not warm, and the presence of neurovascular changes points away from cellulitis.

Deep vein thrombosis

🔷 Deep vein thrombosis can cause pain, swelling, and warmth, but it does not usually cause a hard compartment, marked neurologic symptoms, and worsening arterial perfusion signs like this.

🔷 The combination of coolness, paresthesia, and decreased pulse is more consistent with compartment syndrome than DVT.

Actions

Loosen surgical dressings.

🔶 The nurse should loosen surgical dressings because tight dressings can worsen pressure within the affected compartment.

🔶 In compartment syndrome, any external constriction can further impair blood flow and increase tissue ischemia.

🔶 Loosening restrictive dressings is an immediate nursing intervention to help reduce added compression while the provider is notified.

🔶 This action does not cure compartment syndrome, but it can help prevent further loss of circulation while urgent treatment is arranged.

🔶 For these reasons, loosening surgical dressings is an appropriate action.

Remove pillow elevating right lower extremity.

💎 The nurse should remove the pillow elevating the right lower extremity because excessive elevation can reduce arterial blood flow to an already compromised limb.

💎 In suspected compartment syndrome, the extremity should be kept at heart level, not elevated high above it.

💎 Keeping the leg too high can worsen ischemia by decreasing perfusion to tissues that are already under pressure.

💎 This client already has cool skin, decreased pulse, numbness, and severe pain, all of which show impaired circulation.

💎 For these reasons, removing the pillow elevating the right lower extremity is an appropriate immediate action.

Draw blood for PT and PTT.

🔶 PT and PTT are clotting studies and are not the priority intervention for a client showing classic signs of acute compartment syndrome.

🔶 The immediate concern is restoring and protecting neurovascular perfusion, not evaluating coagulation status.

Prepare to insert a peripherally inserted central catheter.

🔶 A PICC line is not an immediate intervention for acute compartment syndrome.

🔶 This action does not address the urgent problem of increasing compartment pressure and threatened circulation.

Prepare for administration of corticosteroids.

🔶 Corticosteroids are not the standard priority treatment for compartment syndrome.

🔶 The problem is mechanical pressure inside the compartment, which requires pressure relief rather than steroid therapy.

Parameters

Increasing pain level

✅ Increasing pain level is one of the most important parameters to monitor because worsening pain is a key sign that compartment pressure is rising.

✅ Pain in compartment syndrome is often severe, persistent, and greater than expected for the injury or surgery.

✅ The change from pain 4/10 at 0700 to pain 9/10 at 1700 already shows significant deterioration.

✅ Monitoring pain trends helps the nurse evaluate whether the condition is improving or progressing despite interventions.

Capillary refill

🟣 Capillary refill should be monitored because it reflects the adequacy of peripheral perfusion to the affected extremity.

🟣 In compartment syndrome, rising pressure decreases blood flow, which can delay capillary refill.

🟣 Monitoring capillary refill helps the nurse identify whether circulation is worsening or improving after interventions.

🟣 This parameter works together with pulse, skin temperature, sensation, and pain to evaluate the neurovascular status of the limb.

🟣 For these reasons, capillary refill is an important parameter to monitor.

✅ For these reasons, increasing pain level is an essential parameter to monitor.

WBC count

✅ WBC count is more helpful when monitoring for infection, such as cellulitis or osteomyelitis, than for compartment syndrome.

✅ This client’s urgent problem is impaired perfusion and nerve compression, not an infectious process.

Level of consciousness

✅ Level of consciousness is always important in general assessment, but it is not one of the most specific parameters for tracking the progress of compartment syndrome in this extremity.

✅ Neurovascular changes in the affected limb are more directly useful than mental status for evaluating this condition.

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Answer 4

Correct Answers:

A client who has difficulty swallowing

Rationale :

🔷 A speech-language pathologist should be consulted for a client who has difficulty swallowing because this specialist evaluates and treats dysphagia.

🔷 Swallowing problems increase the risk for aspiration, choking, malnutrition, and dehydration.

🔷 The speech-language pathologist can assess the client’s swallow reflex, recommend safe food textures, and teach swallowing techniques.

🔷 This referral is especially important when oral intake is unsafe or ineffective.

🔷 For these reasons, a client who has difficulty swallowing is the client who needs referral to a speech-language pathologist.

A client who requires special eating utensils

🔷 A client who needs special eating utensils is more appropriate for referral to occupational therapy.

🔷 Occupational therapists help clients adapt self-feeding and daily living tasks through assistive devices.

A client who has progressive muscle weakness

🔷 Progressive muscle weakness is more commonly addressed initially by physical therapy or by the provider depending on the cause.

🔷 This finding does not specifically point to the need for a speech-language pathologist unless swallowing or speech is also impaired.

A client who requires oxygen during ambulation

🔷 A client who needs oxygen during ambulation is more appropriate for respiratory support and mobility planning, not speech therapy.

🔷 This need is more closely associated with respiratory therapy or physical rehabilitation services.

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Answer 5

Correct Answers:

Social worker

Rationale :

🔶 A social worker is the most appropriate referral for a client requesting family therapy because social workers commonly provide counseling and connect families with mental health resources.

🔶 They help clients address family conflict, coping issues, communication problems, and psychosocial stressors.

🔶 Social workers also coordinate care and connect the client to community-based therapy services when needed.

🔶 This role fits the client’s request for family-focused emotional and relational support.

🔶 For these reasons, the nurse should initiate a referral to the social worker.

Occupational therapist

🔶 An occupational therapist focuses on improving functional ability in activities of daily living.

🔶 This discipline is not the primary resource for family therapy.

Recreational therapist

🔶 A recreational therapist uses leisure activities to improve well-being and function.

🔶 This team member is not the main professional to arrange family counseling or therapy.

Paramedical technologist

🔶 A paramedical technologist does not provide family therapy or counseling services.

🔶 This role is unrelated to the client’s request for psychosocial intervention.

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Answer 6

Correct Answers:

Hepatosplenomegaly

Rationale :

💎 In right ventricular heart failure, blood backs up into the systemic venous circulation, which can enlarge the liver and spleen.

💎 This backup causes congestion in abdominal organs and leads to findings such as hepatomegaly, splenomegaly, ascites, and peripheral edema.

💎 Hepatosplenomegaly is therefore an expected manifestation of right-sided heart failure.

💎 Right-sided failure is more associated with systemic congestion than with pulmonary fluid buildup.

💎 For these reasons, hepatosplenomegaly is the expected finding.

Crepitus

💎 Crepitus is not a typical manifestation of right ventricular heart failure.

💎 It is more commonly associated with joint problems, fractures, or air in soft tissues.

Elevated pulmonary artery pressure

💎 Elevated pulmonary artery pressure may contribute to right-sided heart failure, but it is not the most direct expected physical finding asked for here.

💎 The clearer client finding of right-sided systemic congestion is hepatosplenomegaly.

Confusion

💎 Confusion can occur with poor perfusion or hypoxia, but it is not the classic hallmark finding of right ventricular failure.

💎 Right-sided failure more commonly presents with systemic venous congestion.

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Answer 7

Correct Answers:

Pertussis

Rationale :

✅ Pertussis requires droplet precautions because it spreads through respiratory droplets produced by coughing and sneezing.

✅ Droplet precautions help prevent transmission to staff, other clients, and visitors.

✅ A client with pertussis should be placed in a private room when possible, and staff should wear a mask when entering.

✅ Early isolation is important because pertussis is highly contagious.

✅ For these reasons, the nurse should implement droplet precautions for pertussis.

Varicella-zoster

✅ Varicella-zoster requires airborne and contact precautions, not droplet precautions alone.

✅ This is because the virus can remain suspended in the air and also spread by direct contact.

Vancomycin-resistant enterococcus (VRE)

✅ VRE requires contact precautions because it spreads through direct contact with contaminated hands or surfaces.

✅ Droplet precautions are not the correct isolation category for VRE.

Rotavirus

✅ Rotavirus requires contact precautions because it spreads through the fecal-oral route and contaminated surfaces.

✅ Droplet precautions are not the primary isolation method for this infection.

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Answer 8

Correct Answers:

Realign the extremity in traction.

Rationale :

🟣 If a client in skeletal traction reports pain from muscle spasms, the nurse should first assess alignment and realign the extremity in traction if needed.

🟣 Muscle spasms can occur when the traction is not maintaining proper alignment of the fractured bone and surrounding muscles.

🟣 Correct alignment helps reduce muscle tension and improves the effectiveness of traction.

🟣 The nurse should maintain the prescribed traction setup while ensuring the line of pull is correct.

🟣 For these reasons, realigning the extremity in traction is the appropriate action.

Remove the traction weights

🟣 The nurse should not remove the traction weights unless there is a specific provider prescription.

🟣 Removing the weights interrupts the therapeutic pull and can worsen pain and fracture alignment.

Increase the amount of traction

🟣 The nurse should not independently increase the traction weight because this requires a provider prescription.

🟣 Increasing the force can cause harm and is not a routine nursing response to muscle spasms.

Allow the weights to rest on the floor

🟣 Traction weights must hang freely to maintain constant therapeutic pull.

🟣 Letting them rest on the floor makes the traction ineffective.

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Answer 9

Correct Answers:

Hepatitis C

Rationale :

🔵 Atorvastatin is contraindicated or used with extreme caution in clients with active liver disease, including hepatitis C with liver involvement, because statins can affect liver function.

🔵 This medication is metabolized in the liver and may worsen hepatic injury or increase liver enzyme levels.

🔵 Clients with liver disease have a greater risk of adverse effects when taking statins.

🔵 Before starting atorvastatin, the nurse should consider the client’s hepatic status carefully.

🔵 For these reasons, hepatitis C is the contraindicating condition among the options provided.

Crohn's disease

🔵 Crohn’s disease is not a direct contraindication to atorvastatin.

🔵 Although overall medication tolerance should be monitored, this condition does not specifically prevent statin use.

Peptic ulcer disease

🔵 Peptic ulcer disease is not a primary contraindication to atorvastatin.

🔵 Statins are more concerning in clients with hepatic disease than in those with gastric ulcer history.

Bronchitis

🔵 Bronchitis does not contraindicate the use of atorvastatin.

🔵 This respiratory condition is unrelated to the major safety concern of liver toxicity with statins.

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Answer 10

Correct Answers:

Improve joint functioning.

Rationale :

⭐ Chondroitin and glucosamine are commonly used to support joint health and may help improve joint comfort and function, especially in osteoarthritis.

⭐ These supplements are thought to support cartilage structure and reduce joint stiffness in some clients.

⭐ They are not a cure, but some clients report mild improvement in mobility and pain.

⭐ Their intended use is musculoskeletal rather than psychiatric, immune, or prostate-related.

⭐ For these reasons, the health benefit of this supplement combination is to improve joint functioning.

Treat mild to moderate depression

⭐ Chondroitin and glucosamine are not used to treat depression.

⭐ Their primary role is related to joint support, not mood management.

Enhance the immune system

⭐ These supplements are not primarily taken to enhance immune function.

⭐ Their most common use is for joint and cartilage support.

Prevent and treat prostate enlargement

⭐ Prostate enlargement is not the therapeutic target of chondroitin and glucosamine.

⭐ These supplements are used for joint symptoms, not urinary or prostate disorders.

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Predictor Assessment 2026

No.

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?

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Predictor Assessment 2026

No.

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?