NURSING NCLEX Module 5 Exam Questions and Answers,100% CORRECT

NURSING NCLEX Module 5 Exam Questions and Answers Module 5 Exam Questions 1. 1.ID: A client with leukemia is being considered for a bone marrow transplant. The healthcare team is discussing the risks and benefits of this treatment and other possible treatments with the goal of inflicting the least possible harm on the client. Which principle of healthcare ethics is the team practicing? A. Justice B. Fidelity C. Autonomy D. Nonmaleficence Correct Rationale: Nonmaleficence is the avoidance of hurt or harm. Remember that in healthcare ethics, ethical practice involves not only the will to do good but also the equal commitment to do no harm. Healthcare professionals try to balance the risks and benefits of a plan of care while striving to do the least possible harm. Justice refers to fairness and equity and ensuring fair allocation of resources, such as nursing care for all clients. Fidelity is the keeping of promises made to clients, families, and other healthcare professionals. Autonomy refers to a person’s independence and represents an agreement to respect another’s right to determine his or her course of action. Test­Taking Strategy: Use the process of elimination and think about the definition of each item in the options. Note the relationship of the words “least possible harm” in the question and the definition of nonmaleficence. Review the principles of healthcare ethics if you had difficulty with this question. Reference: Potter, P., & Perry, A. (2009). Fundamentals of nursing (7th ed., p. 314). St. Louis: Mosby. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Ethical/Legal Awarded 1.0 points out of 1.0 possible points. 2. 2.ID: Which action by the nurse represents the ethical principle of beneficence? A. The nurse upholds a client’s decision to refuse chemotherapy for lung cancer. B. The nurse follows a plan of care designed to relieve pain in a client with cancer. C. The nurse administers an immunization to a child even though it may cause discomfort. Correct D. The nurse provides equal amounts of care to all assigned clients on the basis of illness acuity. Rationale: Beneficence is taking action to help others. Although administration of a child’s immunization might cause discomfort, the benefits of protection from disease outweigh the temporary discomfort. Fidelity is keeping promises made to clients, families, and other healthcare professionals. Autonomy is a person’s independence. Respecting another’s autonomy means that you are agreeing to respect that person’s right to determine his or her course of action. Justice refers to fairness and equity, including fair allocation of resources, such as nursing care for all clients. Test­Taking Strategy: Focus on the subject, beneficence. Recalling that beneficence refers to taking action to help others will direct you to the correct option. Review the principles of healthcare ethics if you had difficulty with this question. Reference: Potter, P., & Perry, A. (2009). Fundamentals of nursing (7th ed., p. 314). St. Louis: Mosby. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Ethical/Legal Awarded 1.0 points out of 1.0 possible points. 3. 3.ID: The nursing instructor asks a student to name an example of false imprisonment. Which of the following situations reflects a violation of this client right? A. Performing a procedure without consent B. Telling the client that he or she may not leave the hospital Correct C. Threatening to give a client a medication against his or her will D. Observing the provision of care to the client without the client’s permission Rationale: Telling a client that he or she may not leave the hospital constitutes false imprisonment. Performing a procedure without consent is an example of battery. Threatening to give a client a medication against his or her will is assault. Invasion of privacy takes place with unreasonable intrusion into an individual’s private affairs. Observing the provision of care to a client without the client’s permission is an example of invasion of privacy. Test­Taking Strategy: Focus on the subject, an example of false imprisonment. Note the relationship of the subject and the words in the correct option. If you had difficulty with this question, review the concept of false imprisonment. References: Cherry, B., & Jacob, S. (2008). Contemporary nursing issues: Trends & management (4th ed., pp. 175, 176). St. Louis: Mosby. Zerwekh, J., & Claborn, J. (2009). Nursing today: Transition and trends (6th ed., p. 424). Cognitive Ability: Evaluating Client Needs: Safe and Effective Care Environment Integrated Process: Teaching and Learning Content Area: Ethical/Legal Awarded 1.0 points out of 1.0 possible points. 4. 4.ID: A nurse and a nursing assistant enter a client’s room to provide care and find the client lying on the floor. The nurse should first: A. Ask the nursing assistant to complete an incident report B. Check the client’s level of consciousness and vital signs Correct C. Ask the nursing assistant to assist in getting the client back to bed D. Contact the unit secretary on the intercom and ask that the client’s physician be called Awarded 1.0 points out of 1.0 possible points. 5. 5.ID: Which of the following actions exemplifies the use of evidence­based practice in the delivery of client care? A. Donning sterile gloves to change an abdominal wound dressing Correct B. Encouraging a client to take an herbal substance to treat his insomnia C. Advising a client to agree to the treatment recommended by her physician D. Taking a rectal temperature from a client for whom bleeding precautions have been instituted Awarded 1.0 points out of 1.0 possible points. 6. 6.ID: The registered nurse has accepted a new position as case manager in a hospital. Which of the following responsibilities are part of the nurse’s new role? Select all that apply. A. Evaluating and updating the plan of care as needed Correct B. Prescribing treatments specific to the client’s needs C. Assessing the client’s needs for home supplies and equipment Correct D. Coordinating consultations and referrals to facilitate discharge Correct E. Establishing a safe and cost­effective plan of care with the client Correct Rationale: A case manager is a nurse who assumes responsibility for coordinating the client's care from the point of admission through, and after, discharge. Specific responsibilities of the case manager include establishing a safe and cost­effective plan of care with the client, coordinating consultations and referrals, and facilitating discharge; initiating a plan of nursing care, care map, or clinical pathway as appropriate to guide care and evaluating and updating the plan of care as needed; ensuring that the plan of care is tailored to the client’s needs, taking into account the client’s diagnosis, self­care ability, and prescribed treatments; assessing the client’s need for equipment such as oxygen or wound care supplies and exploring available resources to provide the client with these supplies; providing resources that will assist the client in maintaining independence as much as possible; and providing the client with information on discharge procedures and the plan of care. The nurse does not prescribe treatments. Test­Taking Strategy: Focus on the subject, the responsibilities of the case manager. Note the word “prescribing” in the incorrect option. It is not within the role of the nurse to prescribe. Review the responsibilities of the case manager if you have difficulty with this question. Reference: Potter, P., & Perry, A. (2009). Fundamentals of nursing (7th ed., p. 21). St. Louis: Mosby. Cognitive Ability: Understanding Client Needs: Safe and Effective Care Environment Awarded 1.0 points out of 1.0 possible points. 7. 7.ID: The nurse manager of a quality improvement program asks a nurse in the neurological unit to conduct a retrospective audit. Which of the following actions should the auditing nurse plan to perform in this type of audit? A. Checking the documentation written by a new nursing graduate on her assigned clients at the end of the shift B. Checking the crash cart to ensure that all needed supplies are readily available should an emergency arise C. Reviewing neurological assessment checklists for all clients on the unit to ensure that these assessments are being conducted as prescribed D. Obtaining the assigned medical record from the hospital’s medical record room to review documentation made during a client’s hospital stay Correct Rationale: Quality improvement, also known as performance improvement, is focused on processes or systems that significantly contribute to client safety and effective client care outcomes. Criteria are used to assess outcomes of care and determine the need for changes improve the quality of care. In a retrospective, or “looking back,” audit, the medical record is inspected after the client’s discharge for documentation of compliance with standards. In a concurrent, or “at the same time,” audit, the nursing staff’s compliance with predetermined standards and criteria is assessed as the nurses are providing care during the client’s stay. In this type of audit, a peer review approach in which members of the nursing staff are involved in data collection may be implemented. Obtaining the a client’s medical record from the medical record room for the purpose of reviewing documentation made during the client’s hospital stay is an example of a retrospective audit. The incorrect options are examples of concurrent audits. Test­Taking Strategy: Focus on the subject, a retrospective audit. Note the relationship of the word “retrospective” in the question and the description in the correct option. Review the procedures for quality improvement and retrospective and concurrent audits if you have difficulty with this question. Reference: Potter, P., & Perry, A. (2009). Fundamentals of nursing (7th ed., pp. 64, 65). St. Louis: Mosby. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Awarded 1.0 points out of 1.0 possible points. 8. 8.ID: A nurse preparing a client for a bronchoscopy notes that the client is wearing a gold necklace. What should the nurse do to safeguard the client’s necklace? A. Ask the client whether the necklace is gold B. Ask the client for permission to lock the necklace in the hospital safe Correct C. Ask the client to remove the necklace and place it in the top drawer of the bedside table D. Ask the client to sign a release to free the hospital of responsibility if the necklace is damaged or lost during the procedure Rationale: When a client has valuables, the nurse should give them to a family member or secure them for safekeeping. Most healthcare institutions require that a client sign a release form that frees the institution of responsibility if a valuable item (e.g., jewelry, money) is lost, but this does not safeguard the client’s necklace. Valuables may be locked in a designated location such as the hospital’s safe. Removing the necklace and putting it in a drawer does not safeguard it. Asking the client whether the necklace is gold is inappropriate and unrelated to the subject. Test­Taking Strategy: Use the process of elimination and focus on the subject, safeguarding the client’s necklace. Focusing on the subject and noting the word “lock” in the correct option will help you answer correctly. Review the procedures for safeguarding a client’s valuables if you had difficulty with this question. Reference: Potter, P., & Perry, A. (2009). Fundamentals of nursing (7th ed., p. 1387). St. Louis: Mosby. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Ethical/Legal Awarded 1.0 points out of 1.0 possible points. 9. 9.ID: A nurse providing preoperative care to a client who is scheduled for a left mastectomy and axillary lymph node dissection notes that the client is wearing a wedding band on her left ring finger. The nurse should: A. Tape the wedding band in place B. Explain to the client why the wedding band must be removed Correct C. Ask the client whether she would like to remove the wedding band or wear it to surgery D. Ask the client to sign a release to free the hospital of responsibility if the wedding band is lost during surgery Rationale: In most situations a wedding band may be taped in place and worn during a surgical procedure. However, if the possibility exists that the client will experience swelling of the hand or fingers, the wedding band should be removed. On admission to a healthcare facility, the client is asked to sign a form that frees the agency from responsibility if a client’s valuable is lost. After mastectomy with axillary lymph node dissection, the client is at risk for lymphedema, which results in swelling of the arm and hand on the affected side. Therefore the appropriate nursing action is to ask the client to remove the wedding band and explain why. Test­Taking Strategy: Use the process of elimination and focus on the data in the question. Eliminate the options that are comparable or alike in that they indicate that the client may wear the wedding band during the surgical procedure. Next, recall the complications associated with mastectomy, which will direct you to the correct option. Review preoperative procedures for a client’s valuables if you had difficulty with this question. Reference: Potter, P., & Perry, A. (2009). Fundamentals of nursing (7th ed., p. 1387). St. Louis: Mosby. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Perioperative Care Awarded 1.0 points out of 1.0 possible points. 10. 10.ID: A nurse preparing a client to go to the radiology department for a chest x­ray notes that the client is wearing a religious medal on a chain around the neck. The client, a Catholic, expresses a concern about removing the medal. What is the most appropriate action for the nurse to take? A. Asking the client to remove the medal until the x­ray has been completed B. Assisting the client in pinning the medal and chain to the waistband of the client’s pajama bottoms Correct C. Asking the client to place the medal in the top drawer of the bedside stand just before leaving for the radiology department D. Telling the client that the medal and chain will be kept at the nurses’ station for safekeeping while the client is undergoing the x­ray Rationale: A client undergoing a chest x­ray must remove all metal objects to help prevent artifacts on the x­ray. If the client expresses concern about removing the medal, the nurse should help the client pin the medal and chain to the hospital gown or in another area where it will not appear on the x­ray image. The nurse should also alert staff in the radiology department that this has been done. If the client is expressing concern about removing the medal, asking the client to remove it or leave it with the nurse or in the bedside stand is inappropriate. Each of these actions also increases the likelihood that the medal and chain will be lost. Test­Taking Strategy: Use the process of elimination and note that the client is expressing concern about removing the religious medal. Eliminate the options that are comparable or alike in that they indicate that the client should remove the medal. Also note that the correct option is the only option that addresses the client’s concern. Review care of clients’ valuables if you had difficulty with this question. Reference: Potter, P., & Perry, A. (2009). Fundamentals of nursing (7th ed., p. 1387). St. Louis: Mosby. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Safety Awarded 1.0 points out of 1.0 possible points. 11. 11.ID: A physician writes a medication prescription in a client’s record. While transcribing the prescription, the nurse notes that the prescribed dose is three times higher than the recommended dose. The nurse calls the physician, who states that this is the dose that the client takes at home and that it is acceptable for this client’s condition. What is the appropriate action for the nurse to take? A. Contacting the nursing supervisor Correct B. Continuing to transcribe the prescription C. Asking the nurse assigned to care for the client to administer the medication D. Verifying the prescribed dose with the client before administering the medication Rationale: A nurse must follow a physician’s prescription unless he or she believes that the prescription is in error or that it would harm the client. If a prescription is found to be incorrect or harmful, further clarification from the physician is necessary. If the physician confirms the prescription and the nurse still believes that it is inappropriate, the nurse should contact the nursing supervisor. The nurse should not continue transcribing the prescription or ask another nurse to implement the prescription. The nurse might ask the client about the medication and the dose taken at home but would not administer the medication. Test­Taking Strategy: Use the process of elimination. Eliminate the options that are comparable or alike in that they indicate that the medication would be administered. Review the nurse’s responsibilities in regard to a physician’s prescriptions if you had difficulty with this question. Reference: Potter, P., & Perry, A. (2009). Fundamentals of nursing (7th ed., p. 709). St. Louis: Mosby. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Ethical/Legal Awarded 1.0 points out of 1.0 possible points. 12. 12.ID: A nurse monitoring a client with a chest tube notes that there is no tidaling of fluid in the water seal chamber. After further assessment, the nurse suspects that the client’s lung has reexpanded and notifies the physician. The physician verifies with the use of a chest x­ray that the lung has reexpanded, then calls the nurse to asks that the chest tube be removed. The nurse should first: A. Call the nursing supervisor B. Explain the procedure to the client, then remove the chest tube C. Inform the physician that removal of a chest tube is not a nursing procedure Correct D. Obtain petrolatum­impregnated gauze and ask another nurse to assist in removing the chest tube Rationale: Actual removal of a chest tube is the duty of a physician. Therefore the nurse would first inform the physician that this is not a nursing procedure. If the physician insists that the nurse remove the tube, the nurse must contact the nursing supervisor. Some agency’s policies and procedures may permit an advanced practice nurse (a nurse with a master’s degree in a specialized area of nursing) to remove a chest tube. However, there is no information in the question to indicate that the nurse is an advanced practice nurse. Test­Taking Strategy: Use the process of elimination. Eliminate the options that are comparable or alike in that they indicate that the nurse would remove the chest tube. To select from the remaining options, note the strategic word “first.” The nurse should discuss the prescription with the physician. Review nursing responsibilities with regard to removal of a chest tube if you had difficulty with this question. Reference: Black, J., & Hawks, J. (2009). Medical­surgical nursing: Clinical management for positive outcomes (8th ed., p. 1624). St. Louis: Saunders. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Ethical/Legal Awarded 1.0 points out of 1.0 possible points. 13. 13.ID: A nurse calls a physician to report that a client with congestive heart failure (CHF) is exhibiting dyspnea and worsening of wheezing. The physician, who is in a hurry because of a situation in the emergency department, gives the nurse a telephone prescription for furosemide (Lasix) but does not specify the route of administration. What is the appropriate action on the part of the nurse? A. Calling the physician who gave the telephone prescription to clarify the prescription Correct B. Calling the nursing supervisor for assistance in determining the route of administration C. Administering the medication intravenously, because this route is generally used for clients with CHF D. Administering the medication orally and clarifying the prescription once the physician has finished caring for the client in the emergency department Awarded 1.0 points out of 1.0 possible points. 14. 14.ID: A nurse is assisting a physician in assessing a hospitalized client. During the assessment, the physician is paged to report to the recovery room. The physician leaves the client’s bedside after giving the nurse a verbal prescription to change the solution and rate of the intravenous (IV) fluid being administered. What is the appropriate nursing action in this situation? A. Calling the nursing supervisor to obtain permission to accept the verbal prescription B. Changing the solution and rate of the IV fluid per the physician’s verbal prescription C. Asking the physician to write the prescription in the client’s record before leaving the nursing unit Correct D. Telling the physician that the prescription will not be implemented until it is documented in the client’s record record before leaving the nursing unit. Changing the solution in keeping with the verbal prescription and contacting the supervisor to obtain permission to accept the verbal prescription each imply that the nurse accepts the verbal prescription. Telling the physician that the prescription will not be implemented until it is documented in the client’s record delays necessary treatment. Test­Taking Strategy: Use the process of elimination and note the strategic word “appropriate.” Eliminate the options that are comparable or alike in that they imply acceptance of the verbal prescription by the nurse. To select from the remaining options, recall the guidelines and principles for implementing physician prescriptions. This will direct you to the correct option. Review nursing responsibilities related to verbal prescriptions if you had difficulty with this question. Reference: Potter, P., & Perry, A. (2009). Fundamentals of nursing (7th ed., pp. 699, 700). St. Louis: Mosby. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Ethical/Legal Awarded 1.0 points out of 1.0 possible points. 15. 15.ID: A client scheduled for surgery tells the nurse that he signed an informed consent for the surgical procedure but was never told about the risks of the surgery. The nurse serves as the client’s advocate by: A. Reassuring the client that the risks are minimal B. Calling the surgeon and asking that the risks be explained to the client Correct C. Noting in the client’s record that the client was not told about the risks of the surgery D. Writing a note on the front of the client’s record so that the surgeon will see it when the client arrives in the operating room Awarded 1.0 points out of 1.0 possible points. 16. 16.ID: A nurse is planning to administer an oral antibiotic to a client with a communicable disease. The client refuses the medication and tells the nurse that the medication causes abdominal cramping. The nurse responds, “The medication is needed to prevent the spread of infection, and if you don’t take it orally I will have to give it to you in an intramuscular injection.” Which of the following statements accurately describes the nurse’s response to the client? A. The nurse could be charged with battery. B. The nurse could be charged with assault. Correct C. The nurse is justified in administering the medication by way of the intramuscular route, because the client has a communicable disease. D. The nurse will be justified in administering the medication by the intramuscular route once a prescription has been obtained from the physician. Awarded 1.0 points out of 1.0 possible points. 17. 17.ID: A nurse discovers that another nurse has administered an enema to a client even though the client told the nurse that he did not want one. The most appropriate action for the nurse is to: A. Contact the client’s physician B. Report the incident to the nursing supervisor Correct C. Tell the client that the nurse did the right thing in giving the enema D. Confront the nurse who gave the enema and tell the nurse that she is going to be charged with battery Awarded 1.0 points out of 1.0 possible points. 18. 18.ID: A nurse calls a physician to question a prescription written for a higher­than­normal dosage of morphine sulfate. The physician changes the prescription to a dosage within the normal range, and the nurse documents the new telephone prescription in accordance with the agency’s guidelines in the client’s record. Which other statement does the nurse document in the nursing notes? A. The physician was called to clarify the prescription for morphine sulfate. Correct B. The physician made an error in the written prescription for morphine sulfate. C. The physician was called to correct an error in the dosage of morphine sulfate. D. An incorrect dosage of morphine sulfate was prescribed and the physician was notified. Awarded 1.0 points out of 1.0 possible points. 19. 19.ID: A charge nurse on the 11 pm–to–7 am shift is gathering the nursing staff together to listen to the 3­ to­11 pm intershift report. The charge nurse notes that a staff member has an odor of alcohol on her breath, slurred speech, and an unsteady gait and suspects alcohol intoxication. The charge nurse would most appropriately: A. Send the staff member home Correct B. Ask the staff member how much alcohol she has consumed C. Tell the staff member that she is not allowed to administer medications D. Ask the staff member to rest in the nurses’ lounge until the effects of the alcohol wear off Rationale: When a staff member reports to work in a state of alcohol intoxication, the nurse notes the signs objectively and asks a second person to validate these observations. The nurse also contacts the nursing supervisor. An odor of alcohol, slurred speech, unsteady gait, and errors in judgment are symptoms of intoxication. Client safety is the primary concern. The intoxicated nurse is removed from the situation, confronted briefly and firmly about the behavior, and sent home to rest and recuperate. The incident is recorded and the nurse describes the observations, states the action taken, indicates future plans, and has the staff member sign and date the memo of the recorded incident after returning to work. Refusal to sign and date the memo should be noted by the charge nurse and a witness. Neither asking the staff member to rest in the nurses’ lounge until the effects of the alcohol wear off nor telling the staff member that he or she will not be allowed to administer medications removes the staff member from the client care area, jeopardizing the client’s safety. Asking the staff member how much alcohol she has consumed is confrontational and irrelevant. Test­Taking Strategy: Use the process of elimination, keeping in mind that client safety is the priority. Asking the staff member how much alcohol she has consumed is irrelevant, so eliminate this option. Next eliminate the options that are comparable or alike in that they do not involve removal of the staff member from the client care area. Review nursing responsibilities when substance abuse is suspected in a staff member if you had difficulty with this question. Reference: Marriner­Tomey, A. (2009). Guide to nursing management and leadership (8th ed., pp. 445, 446). St. Louis: Mosby. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Leadership/Management Awarded 1.0 points out of 1.0 possible points. 20. 20.ID: A client asks a nurse about the procedure for becoming an organ donor. The nurse tells the client: A. That anatomical gifts must be made in writing and signed by the client Correct B. To speak with the chaplain about the psychosocial aspects of becoming a donor C. That this decision must be made by the next of kin at the time of the client’s death D. To let the physician know about the request so that it may be documented in the client’s record Rationale: An individual who is at least 18 years old may make an anatomical gift of all or part of the human body. The gift must be made in writing and signed by the donor. If the client cannot sign, the document must be signed by another individual and two witnesses. The physician is informed of the client’s wishes and the client may wish to speak to a chaplain, but the specific procedure requires a written document signed by the client. The family of a deceased client may be asked about organ donation, but this is not the procedure when a living person wishes to become a donor. Test­Taking Strategy: Use the process of elimination and focus on the subject, a client requesting information about organ donation. Eliminate the option using the closed­ended word “must.” To select from the remaining options, remember that an anatomical gift must be made in writing and signed by the client. Review the procedure for organ donation if you had difficulty with this question. Reference: Marriner­Tomey, A. (2009). Guide to nursing management and leadership (8th ed., pp. 498, 499). St. Louis: Mosby. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Ethical/Legal Awarded 1.0 points out of 1.0 possible points. 21. 21.ID: A nurse enters a client’s room to administer a medication that has been prescribed by the physician. The client asks the nurse about the medication. Which response by the nurse is appropriate? A. “It’s to help get rid of the swelling in your feet.” Incorrect B. “You need to discuss this medication with your physician.” C. “I know that it’s for fluid buildup, and I think you’ve taken it before.” D. “It’s called furosemide (Lasix), and it will promote urination and rid your body of the excess fluid. It can cause an alteration in electrolyte levels, so we’ll need to increase the potassium in your diet.” Correct Rationale: A client has the right to be informed of the medication name, purpose, action, and potential undesirable effects of a prescribed medication. The nurse should provide adequate information to the client. Therefore, the appropriate response is the one that is thorough and complete. Referring the client to the physician places the client’s question on hold. The remaining options are incomplete. Test­Taking Strategy: Note the strategic word “appropriate.” Eliminate the option that refers the client to the physician, because it places the client’s question on hold. To select from the remaining choices, find the option that is most complete and thorough. Review client rights in regard to the provision of information about medication if you had difficulty with this question. Reference: Potter, P., & Perry, A. (2009). Fundamentals of nursing (7th ed., p. 709). St. Louis: Mosby. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Teaching and Learning Content Area: Ethical/Legal Awarded 0.0 points out of 1.0 possible points. 22. 22.ID: A nursing student is assigned to care for a client who requires a total bed bath. When the student explains to the client that she is going to gather supplies to administer the bath, the client states, “I don’t want a bath. I’ve been up all night, and I’m clean enough.” The student reports the client’s refusal to the nurse in charge. Which action by the nurse in charge is appropriate? A. Telling the nursing student to allow the client to rest Correct B. Telling the nursing student to give the client the bath anyway C. Telling the client that the physician will be informed of the refusal of care D. Telling the nursing student to persuade the client to have a bath so that the evening shift staff will not have to do it Awarded 1.0 points out of 1.0 possible points. 23. 23.ID: A client with cancer is transported to the radiology department for a bone scan to determine whether the cancer has metastasized to bone. While the client is in the radiology department, the client’s wife arrives for a visit and asks what test is being performed on the client. What should the nurse tell the wife? A. A bone scan is being performed. B. She will have to discuss the prescribed test with the client. Correct C. The radiology department is not clear as to which test has been prescribed. D. She can read the client’s medical record to determine what the physician prescribed. Awarded 1.0 points out of 1.0 possible points. 24. 24.ID: A married couple is attending a hospital program about in vitro fertilization. During the program, a crew from a local television station arrives to film the proceedings because the station is publicizing a series on hospital services. The nurse conducting the program should: A. Allow the television crew to videotape the program B. Explain to the television crew that videotaping is not allowed Correct C. Ask the television crew to interview the individuals attending the program individually D. Allow the television crew to videotape the program as long as they do not publicize that the program is about in vitro fertilization Awarded 1.0 points out of 1.0 possible points. 25. 25.ID: A nurse is taking a morning break with the unit secretary in the nurses’ lounge. The unit secretary says to the nurse, “I read in Mr. Gage’s medical record that he has gonorrhea.” How should the nurse respond to the secretary? A. “Oh, really? I didn’t see that!” B. “We can’t discuss a client’s medical condition.” Correct C. “Yes, that’s why we’ve imposed contact precautions.” D. “Yes, he does, but be sure not to discuss this with anyone else.” Rationale: A client’s medical condition is confidential and should never be discussed with anyone other than the client and the client’s healthcare provider. Therefore the nurse must tell the unit secretary that the client’s condition is not to be discussed. The statements “Yes, he does, but be sure not to discuss this with anyone else” and “Yes, that’s why we’ve imposed contact precautions” both confirm the client’s disease and are therefore inappropriate. Responding, “Oh, really? I didn’t see that!” promotes further discussion of the client’s condition and is inappropriate. Test­Taking Strategy: Use the process of elimination and recall the issues surrounding confidentiality. This will help you eliminate the option that promotes further discussion of the client’s condition. Next, eliminate the options that are comparable or alike in that they confirm the client’s illness. Review the issues surrounding confidentiality if you had difficulty with this question. Reference: Huber, D. (2010). Leadership and nursing care management (4th ed., pp. 156, 157). St. Louis: Saunders. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Ethical/Legal Awarded 1.0 points out of 1.0 possible points. 26. 26.ID: A nurse on the night shift is making client rounds. When the nurse checks a client who is 97 years old and has successfully been treated for heart failure, he notes that the client is not breathing. If the client does not have a do­not­resuscitate (DNR) order, the nurse should: A. Call the client’s physician B. Contact the nursing supervisor for directions C. Administer cardiopulmonary resuscitation (CPR) Correct D. Administer oxygen to the client and call the physician Incorrect Rationale: CPR is an emergency treatment that is provided without client consent unless a DNR order is part of the client’s record. Calling the nursing supervisor for directions, administering oxygen to the client, and calling the physician are all inappropriate actions that would delay necessary treatment. Test­Taking Strategy: Use the process of elimination. Eliminate the options that are comparable or alike in that they delay necessary treatment. Review procedures related to CPR and DNR orders if you had difficulty with this question. References: Cherry, B., & Jacob, S. (2008). Contemporary nursing issues: Trends & management (4th ed., p. 177). St. Louis: Mosby. Marriner­Tomey, A. (2009). Guide to nursing management and leadership (8th ed., pp. 497­498). St. Louis: Mosby. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Ethical/Legal Awarded 0.0 points out of 1.0 possible points. 27. 27.ID: A physician informs a nurse that the husband of an unconscious client with terminal cancer will not grant permission for a do­not­resuscitate (DNR) order. The physician tells the nurse to perform a “slow code” and let the client “rest in peace” if she stops breathing. How should the nurse respond? A. Telling the physician that “slow codes” are not acceptable Correct B. Telling the physician that the client would probably want to die in peace C. Telling the physician that all of the nurses on the unit agree with this plan D. Telling the physician that if the client stops breathing, the physician will be called before any other actions are taken Rationale: The nurse may not violate a family’s request regarding the client’s treatment plan. A “slow code” is not acceptable, and the nurse should state this to the physician. The definition of a “slow code” varies among healthcare facilities and personnel and could be interpreted as not performing resuscitative procedures as quickly as a competent person would. Resuscitative procedures that are performed more slowly than recommended by the American Heart Association are below the standard of care and could therefore serve as the basis for a lawsuit. The other options are therefore inappropriate. Test­Taking Strategy: Focus on the information in the question — specifically, that the spouse will not grant permission for a DNR order. Recalling the procedures for CPR and the ethical/legal guidelines for a DNR order will direct you to the correct option. Review the nurse’s responsibility regarding DNR orders if you had difficulty with this question. Reference: Ignatavicius, D., & Workman, M. (2010). Medical­surgical nursing: Patient­centered collaborative care (6th ed., p. 113). St. Louis: Saunders. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Ethical/Legal Awarded 1.0 points out of 1.0 possible points. 28. 28.ID: A 51­year­old client with amyotrophic lateral sclerosis (Lou Gehrig’s disease) is admitted to the hospital because his condition is deteriorating. The client tells the nurse that he wants a do­not­ resuscitate (DNR) order. The nurse should tell the client that: A. Consent must be obtained from the family B. The physician makes the final decision about a DNR request C. The DNR request should be discussed with the physician, who will write the order Correct D. Oral consent is sufficient and that his request will be honored by all healthcare providers Awarded 1.0 points out of 1.0 possible points. 29. 29.ID: A man who is visiting his wife in a long­term care facility for people with Alzheimer’s disease collapses and is transported to a hospital. The client remains unconscious, and testing reveals that he has cancer that has metastasized to bone, brain, and liver. The nursing staff at the wife’s care facility report to the hospital physician that the client has no other family members and that his wife is mentally incompetent. What information regarding do­not­resuscitate (DNR) orders does the nurse remember? A. That a DNR order may be written by a client’s physician Correct B. That everything possible must be done if the client stops breathing Incorrect C. That medications only may be given to the client if the client stops breathing D. That life support measures will have to be implemented if the client stops breathing Awarded 0.0 points out of 1.0 possible points. 30. 30.ID: A client admitted to the hospital has a do­not­resuscitate (DNR) order in his medical record. The nurse understands that: A. The DNR order may not be changed once it is in effect B. The DNR order requires frequent review as specified by state or agency policy Correct C. The only people who may change the DNR order are members of the client’s immediate family D. The DNR order, as written on admission, must remain in effect for the duration of the client’s hospitalization Awarded 1.0 points out of 1.0 possible points. 31. 31.ID: A registered nurse (RN) is planning client assignments for the day. Which of the following clients should the RN assign to the nursing assistant? A. A client who requires periodic suctioning B. A client who needs a colostomy irrigation C. A client who needs frequent ambulation with a walker Correct D. A client who has undergone an arteriogram and requires close monitoring Rationale: When a nurse delegates aspects of a client’s care to another staff member, he or she is responsible for appropriately assigning tasks on the basis of the educational level and competency of the staff member. Noninvasive interventions such as ambulating a client with a walker may be assigned to a nursing assistant. A client who requires suctioning or one who needs a colostomy irrigation should be assigned to a licensed practical nurse (LPN) because these staff members can perform certain invasive procedures. The client who has undergone an arteriogram should be assigned to either an LPN or an RN because these personnel have the knowledge and education to detect changes in the client’s status that require attention. Test­Taking Strategy: Use the process of elimination, focusing on the subject of the question, assignment to a nursing assistant. Eliminate the options that are comparable or alike in that they involve invasive procedures. To select from the remaining options, think about the education that a nursing assistant receives. The nursing assistant is trained to ambulate a client with an assistive device but does not have the knowledge and education to detect changes in a client’s status. Review the guidelines for delegation of tasks if you had difficulty with this question. Reference: Cherry, B., & Jacob, S. (2008). Contemporary nursing issues: Trends & management (4th ed., pp. 406, 407). St. Louis: Mosby. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Planning Content Area: Delegating/Prioritizing Awarded 1.0 points out of 1.0 possible points. 32. 32.ID: A registered nurse (RN) who has a licensed practical nurse (LPN) and a nursing assistant on the nursing team is planning client assignments for the day. Which of the following clients should the RN assign to the LPN? A. A client on bedrest who needs assistance with feeding B. A client who must be turned and repositioned every 2 hours C. A client receiving oxygen who requires frequent pulse oximetry monitoring and respiratory treatments Correct D. A client with retinal detachment who is wearing eye patches and requires assistance with hygiene measures Rationale: When a nurse delegates aspects of a client’s care to another staff member, he or she is responsible for appropriately assigning tasks on the basis of the educational level and competency of the staff member. A client receiving oxygen who requires pulse oximetry monitoring and respiratory treatments should be assigned to the LPN, because this staff member can perform these tasks and is competent to note changes in the client’s condition. Feeding a client, turning and repositioning a client, and assisting with hygiene measures, all noninvasive interventions, may be assigned to a nursing assistant. Test­Taking Strategy: Use the process of elimination, focusing on the subject of the question, assignment of tasks to an LPN. Think about the activities that the LPN is able to perform. Next, eliminate the options that are comparable or alike in that they are noninvasive procedures. Review the principles of delegating tasks if you had difficulty with this question. Reference: Cherry, B., & Jacob, S. (2008). Contemporary nursing issues: Trends & management (4th ed., pp. 406, 407). St. Louis: Mosby. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Planning Content Area: Delegating/Prioritizing Awarded 1.0 points out of 1.0 possible points. 33. 33.ID: A registered nurse (RN) in charge of a long­term care facility who is working with a nursing assistant on the night shift prepares to take her break. To ensure client safety during her break, which of the following actions should the nurse take? Select all that apply. A. Conducting client rounds before taking the break Correct B. Taking the break in the staff lounge located on the nursing unit Correct C. Asking the nursing assistant to administer a medication placed at the client’s bedside if the client awakens D. Asking the nursing assistant to monitor a client’s tube feeding and to contact the nurse when the feeding bag is empty E. Asking the nursing assistant to contact the physician during the nurse’s break if a client’s pain medication is not effective F. Informing the nursing assistant that she is leaving the nursing unit to get a cup of coffee from a vending machine in the lobbyIncorrect Rationale: The RN is responsible for ensuring client safety at all times and must not leave the nursing unit for any reason during the shift. The nurse’s break should be taken in a designated area located on the nursing unit. Before taking the break, the nurse should check all clients to ensure that they are safe and comfortable and that their needs have been met. A nursing assistant should never be asked to perform any activity that he or she is not trained for. This includes such activities as administering medications; assessing, monitoring, or evaluating the client; and making decisions about contacting a physician. Test­Taking Strategy: Think about the roles and responsibilities of the RN and the tasks or activities that the nursing assistant may legally perform and focus on the subject, safety. Remember that the registered nurse is responsible for administering medications; assessing, monitoring, and evaluating the client; and making decisions about contacting a physician. Review the role of the RN and the tasks and activities that may be delegated to a nursing assistant if you had difficulty with this question. References: Huber, D. (2010). Leadership and nursing care management (4th ed., pp. 242, 243). St. Louis: Saunders. Potter, P., & Perry, A. (2009). Fundamentals of nursing (7th ed., pp. 400­402). St. Louis: Mosby. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Ethical/Legal Awarded 0.0 points out of 1.0 possible points. 34. 34.ID: A nurse is providing a change­of­shift report on his assigned clients, using an audiotape. Which of the following pieces of information should the nurse include in the report about each assigned client? Select all that apply. A. Family history B. Client needs and priorities of care Correct C. Current diagnosis and any secondary diagnoses Correct D. Results of laboratory studies conducted that day Correct E. Client response to treatments implemented that day Correct F. The steps used to perform the procedure for changing the client’s sterile dressing at the gastrostomy tube site Rationale: A change­of­shift report ensures continuity of care among nurses caring for a client and informs the nurse on the next shift about the client's needs and priorities for care. It may be given written, orally, by audiotape, or while the nurses are walking rounds at a client's bedside. The report should describe the client's health status, current and secondary diagnoses, results of laboratory or diagnostic studies done that day, and the client’s response to treatments implemented that day. The client’s family history does not need to be described in a change­of shift report, and doing so would take time. If such information is needed by the oncoming nurse, it may be obtained from the client’s medical record. There is no useful reason for describing a routine procedure; this would also take time, and the information is available in the agency procedure manual. Test­Taking Strategy: Focus on the subject, what to include in the change­of­shift report. Read each option carefully and eliminate family history, because it is not directly related to the client’s current status. Next eliminate the option that involves describing the steps in performing a procedure, because this is routine information. Also note that the correct options are client focused. Review the components of a change­of­shift report if you had difficulty with this question. Reference: Potter, P., & Perry, A. (2009). Fundamentals of nursing (7th ed., pp. 400­402). St. Louis: Mosby. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Communication and Documentation Content Area: Leadership/Management Awarded 0.0 points out of 1.0 possible points. 35. 35.ID: A nurse working the 7 am–to–3 pm shift is reviewing the records of her assigned clients. Which client should the nurse assess first? A. A client scheduled for hemodialysis at 10 am Correct B. A client scheduled for a nuclear scanning procedure at 10 am C. A client scheduled for contrast computed tomography (CT) at noon D. A client scheduled for hydrotherapy for treatment of a burn injury at 10:30 am Rationale: A client scheduled for hemodialysis has needs that must be met before the procedure. The nurse must ensure that the client is physically and emotionally ready for the treatment, which may take as long as 5 hours. Before the treatment, the nurse must assess the client, including looking for fluid overload by checking the client’s weight and lung sounds. The nurse must also assess the client’s predialysis vital signs and the results of laboratory tests for comparison in the postdialysis period. Although the clients described in the other options have needs, they are not immediate. A client scheduled for a nuclear scanning procedure at 10 am may require reinforcement of information about the procedure and will need to increase fluid intake before the procedure. A client scheduled for hydrotherapy for treatment of a burn injury at 10:30 am may require pain medication, but the medication should be administered approximately 30 minutes before the hydrotherapy. A client scheduled for contrast CT at noon may require reinforcement of information about the procedure and may need to drink a special contrast preparation just before the procedure. Test­Taking Strategy: Use Maslow’s Hierarchy of Needs theory and think about the needs of each client and what pretesting or preprocedure preparation involves. Although all of the clients have physiological needs, the client scheduled for hemodialysis has the priority need, that being the risk of fluid overload. Review the principles of prioritizing if you had difficulty with this question. References: Potter, P., & Perry, A. (2009). Fundamentals of nursing (7th ed., pp. 374, 375). St. Louis: Mosby. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Planning Content Area: Delegating/Prioritizing Awarded 1.0 points out of 1.0 possible points. 36. 36.ID: A nurse has delegated several nursing tasks to staff members. The nurse’s primary responsibility after delegation of the tasks is: A. Documenting completion of each task B. Assigning any tasks that were not completed to the next nursing shift C. Allowing each staff member to make judgments when performing the tasks D. Following up with each staff member regarding the performance of the task and the outcomes related to implementation of the task. Correct Rationale: The ultimate responsibility for a task lies with the person who delegated it. Therefore it is the nurse’s primary responsibility to follow up with each staff member regarding the performance of the task and the outcomes related to implementation of the task. Not all staff members have the education, knowledge, and ability to make judgments about the tasks being performed. The nurse would document that the task was completed, but this would not be done until follow­up had been conducted and outcomes identified. It is not appropriate to assign the tasks that have not been completed to the next nursing shift; this action does not ensure that client needs will be met and also increases the workload for the next shift. Test­Taking Strategy: Use the process of elimination, noting the strategic words “primary responsibility.” Recalling that the ultimate responsibility for a task lies with the person who delegated it will direct you to the correct option. Review the guidelines for delegation if you had difficulty with this question. Reference: Potter, P., & Perry, A. (2009). Fundamentals of nursing (7th ed., pp. 309­311). St. Louis: Mosby. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Leadership/Management Awarded 1.0 points out of 1.0 possible points. 37. 37.ID: A case manager is reviewing progress notes in a client’s medical record. Which notation indicates the need for follow­up? S. No Client Condition Notation 1. Client 1 Status post–mastectomy:18 hours Five milliliters of bloody drainage was emptied from the Jackson-Pratt drain. 2. Client 2 Heart Failure Crackles were heard in the lower lung lobes bilaterally on auscultation. 3. Client 3 Status post–appendectomy: 24 hours The surgical dressing is clean and dry. 4. Client 4 Diabetes mellitus Blood glucose level is124 mg/dL. A. 1 B. 2 Correct C. 3 D. 4 Rationale: A case manager is a nurse who assumes responsibility for coordinating a client's care from the point of admission through, and after, discharge. This nurse initiates a nursing plan of care, care map, or clinical pathway as appropriate to guide care, evaluating and updating the plan of care as needed. The case manager monitors the client for expected and unexpected outcomes and provides follow­up and revises the plan of care if an unexpected outcome is noted. Crackles heard in the lower lobes of the lungs in a client with heart failure are an unexpected and unwanted outcome requiring follow­up because they could indicate the development of pulmonary edema. The notations made for the other clients listed represent expected outcomes. Test­Taking Strategy: Think about the role of the case manager and read each notation carefully. Next, focus on the subject, the need for follow­up. This will direct you to the notation that represents an unexpected or unwanted outcome. Crackles heard in the lower lobes of the lungs on auscultation are a matter of concern. Review the role of the nurse manager and the expected and unexpected findings for the client conditions noted in the options if you had difficulty with this question. Reference: Huber, D. (2010). Leadership and nursing care management (4th ed., pp. 468­469). St. Louis: Saunders. Cognitive Ability: Evaluating Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Evaluation Content Area: Leadership/Management Awarded 1.0 points out of 1.0 possible points. 38. 38.ID: The nurse reviewing a client’s record sees that the following medications are prescribed. Which medication should the nurse plan to administer first? A. 1 Incorrect B. 2 C. 3 D. 4 Correct Rationale: For adequate absorption, levothyroxine must be administered with water on an empty stomach as soon as the client awakens and at least 1 hour apart from other fluids (e.g., coffee or tea), food, and other medications. Therefore this medication should be administered first. Atorvastatin (Lipitor), an HMG–CoA reductase inhibitor used to lower cholesterol, is administered at bedtime because cholesterol synthesis is increased during the night. Zolpidem, a benzodiazepine­ like medication used to enhance sleep, is administered at bedtime. Ferrous sulfate is an iron supplement that is administered with water between meals. Test­Taking Strategy: Note the strategic word “first.” Think about the classification of each medication to determine its action. This will help you answer correctly. Also note that atorvastatin and zolpidem are comparable or alike in that they are administered at bedtime. Next, recalling the action of levothyroxine will direct you to this option. Review the medications in the options and their method of administration if you had difficulty with this question. References: Lehne, R. (2010). Pharmacology for nursing care (7th ed., pp. 380, 570, 694). St. Louis: Saunders. Hodgson, B., & Kizior, R. (2009). Saunders nursing drug handbook 2009 (p. 476). St. Louis: Saunders. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Delegating/Prioritizing Awarded 0.0 points out of 1.0 possible points. 39. 39.ID: A nurse manager has announced a change to computerized documentation of nursing care. A licensed practical nurse (LPN) on the team, resistant to the change, is not taking an active part in facilitating implementation of the new procedure. Which of the following strategies would be the best approach to dealing with the conflict? A. Ignoring the resistance B. Telling the LPN that his noncompliance will be documented in his personnel record C. Confronting the LPN and encouraging him to express his feelings regarding the change Correct D. Telling the LPN that a registered nurse will perform all of the computer documentation if he will document all intake and output and vital signs Rationale: Confrontation is an important strategy in dealing with resistance. Face­to­face meetings to confront the issue at hand allow verbalization of feelings, identification of problems and issues, and development of strategies to solve the problem. Ignoring the resistance does not address the problem. Providing a temporary solution to the resistance by having the registered nurse do all of the computer work and having the LPN perform only specific documentation will not specifically address the concern. Telling the LPN that the noncompliance will be documented in his personnel record may produce additional resistance. Test­Taking Strategy: Focus on the subject, the best approach to dealing with a conflict. Use the process of elimination and eliminate the options that are comparable or alike in that they represent direct avoidance of the conflict. If you had difficulty with this question, review the best approaches to with dealing with conflict. References: Huber, D. (2010). Leadership and nursing care management (4th ed., p. 287). St. Louis: Saunders. Marriner­Tomey, A. (2009). Guide to nursing management and leadership (8th ed., pp. 326, 327). St. Louis: Mosby. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Leadership/Management Awarded 1.0 points out of 1.0 possible points. 40. 40.ID: A registered nurse (RN) is planning client assignments for the day. Which clients should the nurse assign to a nursing assistant (unlicensed assistive personnel)? Select all that apply. A. A client with a permanent tracheostomy B. A client requiring a gastrostomy tube dressing change C. A client who requires transport to the radiology department in a wheelchair Correct D. A client with a Foley catheter for whom a 24­hour urine collection is in progress Correct E. A client who underwent surgery an hour earlier and has a nasogastric tube and a Foley catheter Rationale: The nurse must base assignments on the basis of the skills of the staff member and the needs of the client. The nursing assistant is capable of caring for the client with a Foley catheter for whom a 24­hour urine collection is in progress and the client who requires transport to the radiology department in a wheelchair. The nursing assistant is skilled in such tasks. The client who has just undergone surgery will require specific monitoring in addition to recording of vital signs. Dressing changes and tracheostomy care are not performed by unlicensed personnel. Test­Taking Strategy: Focus on the subject, assignments for the nursing assistant. Think about the skills that the nursing assistant can perform and remember that the nursing assistant may perform tasks that are noninvasive. Review the principles of delegation and assignment­making if you had difficulty with this question. Reference: Huber, D. (2010). Leadership and nursing care management (4th ed., pp. 244­246, 250). St. Louis: Saunders. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Planning Content Area: Delegating/Prioritizing Awarded 1.0 points out of 1.0 possible points. 41. 41.ID: A registered nurse (RN) is planning assignments for five clients on the nursing unit. The team includes a licensed practical nurse (LPN) and a nursing assistant. Which clients should the nurse assign to the LPN? Select all that apply. A. A client who is confused and requires assistance with a shower B. A client requiring a bed bath and frequent ambulation with a cane C. A client who must be accompanied to physical therapy twice during the shift D. A client with a colostomy who requires reinforcement regarding the procedure for irrigation Correct E. A client with diabetes mellitus who requires the administration of regular insulin in accordance with a sliding dosage scale every 4 hours Correct Rationale: When delegating nursing assignments, the nurse must consider the skills and educational level of the nursing staff. The nursing assistant may be assigned the tasks of caring for a confused client, assisting with a shower or a bed bath, ambulating a client with a cane, and accompanying a client to physical therapy. The LPN is educated to reinforce teaching regarding the colostomy irrigation (the RN is responsible for the initial teaching) and administering regular insulin in accordance with a sliding scale. Test­Taking Strategy: Focus on the subject, the client assignment for the LPN. Use the process of elimination to eliminate the clients whose needs are noninvasive, because a nursing assistant may perform these tasks. This will help you identify the clients who may be assigned to the LPN. If you had difficulty with this question, review the principles of delegation and assignment­making. Reference: Huber, D. (2010). Leadership and nursing care management (4th ed., pp. 244­246, 250). St. Louis: Saunders. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursin