Question

A nurse is caring for a client who has osteoarthritis and reports difficulty buttoning their clothes. The nurse should recommend a referral for the client to which of the following members of the interprofessional team?

Answer 1

Correct Answers:

Occupational therapist.

Rationale :

📌An occupational therapist assists clients with regaining the ability to perform activities of daily living (ADLs), including tasks such as dressing, grooming, and eating.

◽Since the client is experiencing difficulty buttoning clothes, which is a fine motor skill, an OT is best equipped to evaluate and recommend adaptive techniques or assistive devices to improve independence.

◽ A podiatrist specializes in foot care, a social worker assists with psychosocial needs, and a paramedical technologist does not typically address functional activities.

◽Referring the client to the appropriate team member ensures interprofessional collaboration for optimal outcomes.

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Answer 2

Correct Answers:

"Take vital signs every 2 hours for the client who had a cholecystectomy in room 6122."

Rationale :

✅This instruction is the most specific, measurable, and clearly defined, which is critical for effective delegation.

◼It includes what to do, how often, for whom, and where, enabling the assistive personnel (AP) to perform the task without ambiguity.

◼Delegation requires clear communication to ensure safety and accountability.

◼Options B, C, and D lack sufficient detail or assign responsibilities outside the AP's scope, such as clinical judgment in option C.

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Answer 3

Correct Answers:

Interpreter.

Rationale :

🧩When a language barrier exists, it is essential to use a qualified medical interpreter for accurate and safe communication, especially when discussing complex medical procedures.

🧩This ensures informed consent and promotes client autonomy.

🧩Using family or unqualified staff can result in miscommunication or legal liability.

🧩The interpreter ensures the client receives and understands information in a culturally and linguistically appropriate manner.

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Answer 4

Correct Answers:

Platelets 100,000/mm3.

Rationale :

🔹A platelet count of 100,000/mm³ is below the normal range (150,000–400,000/mm³), indicating thrombocytopenia, which places the client at increased risk for bleeding.

🔹This is a priority and requires prompt evaluation.

🔹The other lab values—digoxin, WBCs, and potassium—are within normal limits and do not indicate immediate concern.

🔹 Prioritizing care based on potential for harm aligns with safe practice standards.

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Answer 5

Correct Answers:

State Nurse Practice Act (NPA).

Rationale :

✅The State Nurse Practice Act governs nursing practice and outlines the legal scope of practice for nurses, including procedures like inserting PICC lines.

✅ Any new policy related to nursing responsibilities must comply with the NPA to ensure legal and regulatory compliance.

✅National organizations may provide guidance or best practices, but they do not have the authority of state laws.

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Answer 6

Correct Answers:

Inform the assistive personnel of the client's weight-bearing status.

Rationale :

✴Informing the AP about the client’s weight-bearing status is crucial to prevent injury and ensure safe mobility post-surgery.

✴This promotes interdisciplinary communication and reinforces delegation with essential context.

✴Assessing the incision, instructing clients to cross legs, or flexing hips beyond 90 degrees may pose safety risks or are outside the AP's role.

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Answer 7

Correct Answers:

Review the AP's skill competency checklist.

Rationale :

💠Before delegating a task such as removing an indwelling catheter, the nurse must verify that the AP is competent and authorized to perform the procedure.

💠Reviewing the AP's competency checklist ensures the task is appropriate and safe.

💠Simply asking or showing them the skill does not ensure competence, and pairing with another AP does not confirm qualification.

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Answer 8

Correct Answers:

Discuss the client's concerns about having the surgery.

Rationale :

💥Respect for autonomy means the nurse must support the client's right to make their own decisions and explore their reasoning.

💥Discussing concerns helps the nurse assess whether the client has adequate information and support.

💥 It also strengthens therapeutic communication.

💥 Initiating a consult or providing consequences may feel coercive and disregard the client's current emotional needs.

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Answer 9

Correct Answers:

Remind the staff members that this is a breach of confidentiality.

Rationale :

🌟The nurse should take immediate action to address a breach of confidentiality by stopping the inappropriate behavior.

🌟Reminding staff about confidentiality regulations protects the client’s rights and complies with HIPAA.

🌟 Escalating the issue may be necessary later, but the first action must be to prevent further violation.

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Answer 10

Correct Answers:

Notify the quality improvement team.

Rationale :

🧠An increase in ventilator-associated pneumonia (VAP) suggests a systemic problem affecting client safety.

🧠The quality improvement (QI) team is responsible for investigating trends, identifying causes, and implementing corrective actions.

🧠This collaborative, data-driven approach ensures that patient care is continuously improved.

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RN Leadership 2019 A

No.

1 : A nurse is caring for a client who has osteoarthritis and reports difficulty buttoning their clothes. The nurse should recommend a referral for the client to which of the following members of the interprofessional team?

2 : Which of the following instructions provided by a nurse reflects effective communication regarding delegation of a task to an assistive personnel (AP)?

3 : A nurse is providing preoperative teaching for a client who is scheduled for a total knee arthroplasty and speaks a different language than the nurse. Which of the following interprofessional team members should the nurse include in the discussion?

4 : A home health nurse is planning her daily visits and receives laboratory results for four adult clients. The nurse should first visit the client who has which of the following laboratory values?

5 : A nurse is serving on a committee that is considering the creation of a policy that will allow nurses to insert peripherally inserted central catheters in the intensive care unit. Which of the following resources should the nurse consult in planning for this policy?

6 : A nurse is reviewing the plan of care for a client following a total hip arthroplasty. Which of the following actions should the nurse plan to take?

7 : A nurse asks a newly hired assistive personnel (AP) to remove a client's indwelling urinary catheter. Which of the following actions should the nurse take to ensure the AP is qualified to perform this task?

8 : A nurse is caring for a client who is recovering from a stroke. The provider recommends an extracranial-intracranial bypass, but the client tells the nurse that he will not have the surgery. Which of the following actions should the nurse take?

9 : A nurse walks into the nurses' station and sees several staff members looking at the electronic medical record for a celebrity client on another unit. Which of the following actions should the nurse take first?

10 : A nurse manager is auditing client charts and identifies an increase in ventilator-associated pneumonia (VAP). Which of the following actions should the nurse manager take?

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