a charge nurse is planning care for a group of clients on a medical surgical unit which of the following tasks should the nurse delegate to an assisti
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Nursing Elites

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RN ATI Capstone Proctored Comprehensive Assessment 2019 B

1. A charge nurse is planning care for a group of clients on a medical-surgical unit. Which of the following tasks should the nurse delegate to an assistive personnel (AP)?

Correct answer: D

Rationale: The correct answer is D because measuring hourly urinary output is a task that falls within the scope of practice for assistive personnel. This task involves a technical skill that can be delegated by the charge nurse. Choices A, B, and C require higher-level nursing assessments and interventions that should be performed by licensed nursing staff. Giving a glycerin suppository involves medication administration, evaluating the effectiveness of ibuprofen requires assessment and critical thinking, and discussing dietary changes involves education and assessment of the client's understanding and compliance, all of which are beyond the scope of practice for assistive personnel.

2. A client with a new prescription for sumatriptan tablets to treat migraine headaches should report which of the following symptoms to the nurse?

Correct answer: B

Rationale: The correct answer is B because swelling of the eyelids is a side effect of sumatriptan tablets that requires immediate reporting to the healthcare provider to prevent further complications. Choices A, C, and D are incorrect. Chewing the tablet well before swallowing is not necessary for sumatriptan tablets. Repeating the dose in 1 hour for unrelieved headache is incorrect as this medication should not be repeated within 24 hours. Taking sumatriptan daily for headache prevention is also incorrect as it is used for acute treatment, not prevention.

3. What is an appropriate parenting technique for time-out disciplining in children with mental health issues?

Correct answer: B

Rationale: The correct answer is B: 'Remove all privileges for at least one week following a violation.' When dealing with children with mental health issues, it is essential to have consistent consequences for their actions. Providing positive reinforcement for minor infractions (choice A) may not effectively address inappropriate behaviors that require disciplinary action. Limiting the child's time outside the home environment (choice C) does not directly address the behavioral issue. Using time-out only in severe situations (choice D) may not provide consistent consequences for the child's behavior and can lead to escalation before interventions are used.

4. Which action by the nurse demonstrates effective infection control measures?

Correct answer: A

Rationale: The correct answer is A: Perform hand hygiene before and after patient contact. Effective hand hygiene is a fundamental infection control measure that helps prevent the spread of pathogens. Wearing gloves when administering medications (choice B) is important for protecting both the patient and the nurse but is not a direct demonstration of infection control. Disposing of used equipment in designated containers (choice C) is more related to proper waste management than infection control. Wearing a mask when interacting with the patient (choice D) is essential in certain situations, but hand hygiene is a more universal and critical practice for infection control.

5. A healthcare provider is reviewing the laboratory report of a client who is receiving heparin therapy for a deep vein thrombosis. Which of the following lab values indicates a therapeutic response to the therapy?

Correct answer: B

Rationale: An aPTT of 70 seconds is within the therapeutic range for a client receiving heparin therapy. The activated partial thromboplastin time (aPTT) is the most sensitive test to monitor heparin therapy. A therapeutic aPTT range for a client receiving heparin is usually 1.5 to 2.5 times the control value. Choices A, C, and D are not indicators of a therapeutic response to heparin therapy. PT measures the extrinsic pathway of coagulation and is not specific to monitoring heparin therapy. Platelet count is important to monitor for heparin-induced thrombocytopenia, but it does not indicate the therapeutic response to heparin therapy. INR is used to monitor warfarin therapy, not heparin therapy.

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