the nurse is preparing task assignments for the day which task should the nurse assign to a nursing assistant

NCLEX-PN

NCLEX PN Test Bank

1. The nurse is preparing task assignments for the day. Which task should the nurse assign to a nursing assistant?

A. Monitoring for bleeding for a client who has just undergone cardiac catheterization
B. Assisting a client who is getting up to ambulate for the first time after surgery
C. Providing oral care to an unconscious client who requires oral care
D. Completing the preoperative checklist for a client scheduled for a liver biopsy

Correct answer: Providing oral care to an unconscious client who requires oral care

Rationale: When delegating tasks, the nurse must consider the state nursing practice act guidelines and job descriptions. Providing oral care to an unconscious client is a task suitable for delegation to a nursing assistant. The nurse should give clear instructions on adapting the procedure for the client's needs and the signs of complications to watch for. Monitoring for bleeding after cardiac catheterization necessitates immediate nursing assessment, which requires critical thinking and intervention that exceeds a nursing assistant's scope of practice. Assisting a client with ambulation post-surgery carries the risk of orthostatic hypotension and should be performed by a licensed nurse. Completing a preoperative checklist for a client scheduled for a liver biopsy involves critical assessment and preparation that are within the nurse's scope of practice.

2. The nurse is caring for a client awaiting test results on a biopsy. The client is unconscious, and the physician informs the client’s spouse that the biopsy came back positive for cancer. The spouse asks the nurse if they will not share this news with the client because they would prefer the client be unaware of the diagnosis. Which of the following responses is most appropriate?

A. “I will have a psychiatrist confirm whether the news will cause negative effects, and if so, I will comply with your request.”
B. “For ethical reasons, I am unable to withhold this information from the client.”
C. “You do not have the option to sign paperwork stating you are accepting the risk of not sharing this with the client.”
D. “You must have a durable power of attorney for healthcare advanced directive in place before I can consider this request.”

Correct answer: “For ethical reasons, I am unable to withhold this information from the client.”

Rationale: The correct response is, “For ethical reasons, I am unable to withhold this information from the client.” The ethical principle of veracity requires that the nurse is truthful with the client and does not withhold information even if it is requested by the family. Choice A is incorrect because seeking a psychiatrist's confirmation is not necessary to uphold the ethical principle of truth-telling. Choice C is incorrect as implying that signing paperwork overrides the nurse's ethical obligation to be honest with the client is inappropriate. Choice D is also incorrect as a durable power of attorney is not relevant in this situation where the spouse is asking the nurse to withhold information.

3. When the healthcare provider is determining the appropriate size of a nasopharyngeal airway to insert, which body part should be measured on the client?

A. corner of the mouth to tragus of the ear
B. corner of the eye to top of the ear
C. tip of the chin to the sternum
D. tip of the nose to the earlobe

Correct answer: tip of the nose to the earlobe

Rationale: A nasopharyngeal airway is measured from the tip of the nose to the earlobe. This measurement ensures that the airway is of the correct length to reach the nasopharynx without being too long or too short. Choices A, B, and C are incorrect as they do not provide the appropriate measurement for selecting the correct size of a nasopharyngeal airway. The distance from the corner of the mouth to the tragus of the ear (Choice A) is used to measure for an oropharyngeal airway, not a nasopharyngeal airway. Similarly, the other choices (B and C) do not correlate with the correct measurement of a nasopharyngeal airway.

4. Quality is defined as a combination of all of the following except:

A. conforming to standards.
B. performing at the minimally acceptable level.
C. meeting or exceeding customer requirements.
D. exceeding customer expectations.

Correct answer: performing at the minimally acceptable level.

Rationale: Quality in any context is about meeting or exceeding customer requirements and exceeding customer expectations. It also involves conforming to standards to ensure consistency and reliability. Merely performing at the minimally acceptable level does not encompass the essence of quality, as it sets the bar at the lowest level of acceptability rather than aiming for excellence or customer satisfaction. Therefore, the correct answer is 'performing at the minimally acceptable level,' as this choice falls short in capturing the comprehensive definition of quality.

5. When observing a dressing change by a graduate nurse on a Stage III pressure ulcer to the greater trochanter by the staff nurse, a need for further teaching is indicated after the following observation by the nurse:

A. The new graduate nurse irrigates the pressure ulcer with 50cc of NS.
B. The new graduate irrigates the pressure ulcer with half-strength hydrogen peroxide.
C. The new graduate packs the wound with sterile kerlix soaked in NS.
D. The new graduate applies a Duoderm dressing over the wound after cleansing.

Correct answer: The new graduate irrigates the pressure ulcer with half-strength hydrogen peroxide.

Rationale: The correct answer is that the new graduate irrigates the pressure ulcer with half-strength hydrogen peroxide. Pressure ulcers should not be cleaned with substances that are cytotoxic, such as hydrogen peroxide or betadine. This can cause further damage to the wound and delay the healing process. Choice A is incorrect because irrigating the pressure ulcer with normal saline is an appropriate practice. Choice C is incorrect because packing the wound with sterile kerlix soaked in normal saline is also an appropriate step. Choice D is incorrect because applying a Duoderm dressing after cleansing is a standard procedure in wound care.