Question

A nurse is delegating client care tasks to an assistive personnel. Which of the following tasks should the nurse delegate?

Answer 1

Correct Answers:

Performing a simple dressing change

Rationale :

✅Assistive personnel (AP) may be delegated tasks that are non-invasive, repetitive, and do not require clinical judgment.

✅A simple dressing change, such as covering a dry, intact wound with a non-sterile dressing, meets this criterion—provided it is part of routine care and the wound requires no assessment.

✅However, the registered nurse is still responsible for evaluating the wound, monitoring for signs of infection, and verifying that the AP has the necessary training.

✅Delegation of tasks like this supports time efficiency, appropriate use of resources, and allows the nurse to focus on more critical aspects of care.

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Answer 2

Correct Answers:

I should limit the time that I spend sitting in a chair

Rationale :

⏺Clients at risk for venous thromboembolism (VTE)—including those who are post-surgical, immobile, or have comorbidities—must avoid prolonged sitting.

⏺Venous stasis from immobility promotes clot formation, particularly in the lower extremities.

⏺Encouraging movement, even short walks or frequent position changes, improves circulation and venous return.

⏺Nurses must educate clients to stand, walk, or elevate their legs frequently to reduce VTE risk.

⏺Clients who must sit should be instructed to do so in short intervals with active foot exercises.

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Answer 3

Correct Answers:

BRP for bathroom privileges

Rationale :

🎯The Joint Commission’s "Do Not Use" list specifies that only approved abbreviations should be documented to reduce the risk of misinterpretation, medication errors, and treatment delays.

🎯"BRP" is a recognized and approved abbreviation meaning "bathroom privileges", indicating that a client is allowed to get out of bed to use the restroom.

🎯It is a safe and commonly used term in clinical documentation, unlike non-standard abbreviations which must be avoided.

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Answer 4

Correct Answers:

Present information about the benefits of quitting smoking.

Rationale :

🔴According to Prochaska’s Transtheoretical Model, the contemplation stage is when a client is aware of a problem and begins thinking about change, but is not ready to act.

🔴The nurse’s role here is to support decision-making by providing accurate, non-judgmental education and discussing the benefits of behavior change, such as improved health outcomes from quitting smoking.

🔴The goal is to move the client forward into the preparation stage through motivational conversation, not by forcing change.

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Answer 5

Correct Answers:

A gastric residual of 300 mL at the end of the shift

Rationale :

In clients receiving enteral nutrition, gastric residual volume (GRV) is monitored to assess feeding tolerance and gastric motility.
A residual of 300 mL is considered excessive, suggesting delayed emptying or poor tolerance.
High GRV increases the risk for aspiration, vomiting, or reflux. While GRV thresholds may vary by institution, volumes greater than 250–500 mL usually require holding the feeding, reassessing in 1–2 hours, and notifying the provider.
This promotes client safety and prevention of complications related to enteral feedings.

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Answer 6

Correct Answers:

Aspirate residual volume every 4hr

Rationale :

⚫For clients on continuous enteral feedings, gastric residuals should be aspirated every 4 hours to evaluate the client’s tolerance to the feeding and detect delayed gastric emptying.

⚫Monitoring GRV at regular intervals helps prevent aspiration, regurgitation, and feeding intolerance.

⚫This practice also informs decisions about adjusting the feeding rate or formula and contributes to early recognition of gastrointestinal dysfunction.

⚫Proper documentation of GRV supports safe nutritional therapy.

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Answer 7

Correct Answers:

Schedule the client as the first surgical procedure of the day.

Rationale :

♦Clients with a latex allergy are at significant risk for intraoperative hypersensitivity reactions, including anaphylaxis.

♦To reduce this risk, they should be scheduled as the first surgical case of the day to prevent environmental latex contamination from prior cases and ensure latex-free equipment is in place.

♦Early scheduling allows for extra preparation time and minimizes the presence of airborne latex particles, such as those from gloves or catheters, enhancing overall safety.

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Answer 8

Correct Answers:

Keep the drainage bag below the level of the bladder

Rationale :

💥Positioning the urinary drainage bag below the level of the bladder ensures proper drainage by gravity, reducing the risk of backflow, which can lead to urinary tract infections (UTIs) and contamination of the bladder.

💥Proper placement also maintains closed-system integrity, which is essential in the prevention of catheter-associated urinary tract infections (CAUTIs).

💥Nurses must also ensure that tubing is not kinked and that there is no dependent loop impeding flow.

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Answer 9

Correct Answers:

'New dressing applied as prescribed: no drainage on old dressing.'

Rationale :

👉This documentation is concise, objective, and complete, providing clear information about the condition of the old dressing, absence of drainage (a key wound assessment indicator), and confirmation that the prescribed intervention was completed.

👉Such precise and factual charting is essential for continuity of care, legal documentation, and monitoring wound healing.

👉It reflects nursing accountability and communication with other healthcare professionals.

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Answer 10

Correct Answers:

Cover the area of percussion with a towel.

Rationale :

📌During chest physiotherapy with percussion, a thin towel or cloth should be placed over the chest wall to protect the client’s skin from irritation or bruising while still allowing transmission of the percussive vibrations needed to loosen secretions.

📌This method is particularly important in clients receiving frequent treatments, such as those with cystic fibrosis, chronic bronchitis, or pneumonia, to avoid skin breakdown while promoting effective airway clearance.

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RN Fundamentals 2019~Exam 2

No.

1 :
A nurse is delegating client care tasks to an assistive personnel. Which of the following tasks should the nurse delegate?

2 :
A nurse is providing teaching to a client who is at risk for thrombus formation. Which of the following statements made by the client indicates an understanding of the teaching?

3 :
A nurse is documenting client care. Which of the following abbreviations should the nurse use?

4 :
A nurse is planning care for a client who is concerned about her tobacco smoking habits and is in the contemplation stage of health behavior change. Which of the following actions should the nurse plan to take during this stage?

5 :
A nurse is caring for a client who is receiving continuous enteral feeding via NG tube. Which of the following is an unexpected finding?

6 :
A nurse is caring for a client who is receiving continuous enteral feedings through a gastrostomy tube. Which of the following actions should the nurse take?

7 :
A nurse is planning care for a client who has a latex allergy and is scheduled for surgery. Which of the following actions is appropriate to include in the client's plan of care?

8 :
A nurse is planning care for a female client who has an indwelling urinary catheter. Which of the following actions should the nurse include in the plan?

9 :
A nurse is documenting a dressing change for a client who has a pressure injury. Which of the following entries by the nurse demonstrates correct documentation?

10 :
A nurse is performing postural drainage with percussion and vibration for a client who has cystic fibrosis. Which of the following actions should the nurse take?

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RN Fundamentals 2019~Exam 2

No.

1 : A nurse is delegating client care tasks to an assistive personnel. Which of the following tasks should the nurse delegate?

2 : A nurse is providing teaching to a client who is at risk for thrombus formation. Which of the following statements made by the client indicates an understanding of the teaching?

3 : A nurse is documenting client care. Which of the following abbreviations should the nurse use?

4 : A nurse is planning care for a client who is concerned about her tobacco smoking habits and is in the contemplation stage of health behavior change. Which of the following actions should the nurse plan to take during this stage?

5 : A nurse is caring for a client who is receiving continuous enteral feeding via NG tube. Which of the following is an unexpected finding?

6 : A nurse is caring for a client who is receiving continuous enteral feedings through a gastrostomy tube. Which of the following actions should the nurse take?

7 : A nurse is planning care for a client who has a latex allergy and is scheduled for surgery. Which of the following actions is appropriate to include in the client's plan of care?

8 : A nurse is planning care for a female client who has an indwelling urinary catheter. Which of the following actions should the nurse include in the plan?

9 : A nurse is documenting a dressing change for a client who has a pressure injury. Which of the following entries by the nurse demonstrates correct documentation?

10 : A nurse is performing postural drainage with percussion and vibration for a client who has cystic fibrosis. Which of the following actions should the nurse take?

1 :
A nurse is delegating client care tasks to an assistive personnel. Which of the following tasks should the nurse delegate?

2 :
A nurse is providing teaching to a client who is at risk for thrombus formation. Which of the following statements made by the client indicates an understanding of the teaching?

3 :
A nurse is documenting client care. Which of the following abbreviations should the nurse use?

4 :
A nurse is planning care for a client who is concerned about her tobacco smoking habits and is in the contemplation stage of health behavior change. Which of the following actions should the nurse plan to take during this stage?

5 :
A nurse is caring for a client who is receiving continuous enteral feeding via NG tube. Which of the following is an unexpected finding?

6 :
A nurse is caring for a client who is receiving continuous enteral feedings through a gastrostomy tube. Which of the following actions should the nurse take?

7 :
A nurse is planning care for a client who has a latex allergy and is scheduled for surgery. Which of the following actions is appropriate to include in the client's plan of care?

8 :
A nurse is planning care for a female client who has an indwelling urinary catheter. Which of the following actions should the nurse include in the plan?

9 :
A nurse is documenting a dressing change for a client who has a pressure injury. Which of the following entries by the nurse demonstrates correct documentation?

10 :
A nurse is performing postural drainage with percussion and vibration for a client who has cystic fibrosis. Which of the following actions should the nurse take?