An assistive personnel (AP) reports to the nurse that a client who is 3 days postoperative following an abdominal hysterectomy has a dressing that is saturated with blood. Which of the following tasks should the nurse delegate to the AP?

Correct Answer: B

Rationale: The correct answer is B: Obtain vital signs. The priority in this situation is to assess the client's vital signs to determine the severity of the bleeding and the client's overall condition. The AP can assist by obtaining vital signs, which is within their scope of practice and does not require interpretation. Changing the abdominal dressing (A) should be done by a nurse to assess the wound and control bleeding. Palpating for bladder distention (C) and observing the incision site (D) require more specialized assessment skills and should be done by the nurse.

Correct Answer: A

Rationale: The correct answer is A because it demonstrates negligence by failing to promptly report a concerning finding, which could lead to harm. The nurse's delay in notifying the provider increases the risk of complications for the client. Option B involves deception and administration of medication without consent, which is a violation of the client's autonomy and not negligence. Option C involves inappropriate use of restraints against a competent client's wishes, violating autonomy and not negligence. Option D involves a threat of restraints to enforce dietary restrictions, which is not appropriate but also not a clear example of negligence.

Correct Answer: B

Rationale: The correct answer is B: Assessing a client who experiences unilateral calf pain when ambulating. This is the priority action because unilateral calf pain can be a sign of deep vein thrombosis (DVT), a potentially life-threatening condition. The nurse should assess the client immediately to rule out DVT and prevent complications. Choice A is incorrect because taking a telephone prescription can be delegated to another qualified staff member, and it is not an urgent priority. Choice C is incorrect because reinforcing a dressing for an above-the-knee amputation, while important, is not as urgent as assessing for a potential DVT. Choice D is incorrect because reassuring the partner of a client with a closed head injury, while supportive, is not the priority compared to assessing a client with potential DVT.

Correct Answer: A

Rationale: The correct answer is A: Encourage the client to verbalize questions. This action demonstrates client advocacy by empowering the client to ask questions, express concerns, and actively participate in their care. It promotes informed decision-making and ensures that the client's needs and preferences are considered. Choices B, C, and D are incorrect because they do not prioritize the client's autonomy, rights, and well-being. Insisting the client take prescribed medications (B) disregards the client's right to make decisions about their own care. Informing the client that the medication is the same as taken at home (C) may not address the client's individual concerns or preferences. Telling the client that refusal of the medication is considered noncompliance (D) can be coercive and does not respect the client's right to refuse treatment.

Correct Answer: B

Rationale: The correct answer is B because a positive PPD test with an abnormal chest x-ray indicates tuberculosis (TB), which is an airborne transmitted disease. Airborne precautions are required to prevent the spread of TB. Choice A is incorrect because AIDS with CMV does not require airborne precautions. CMV is primarily transmitted through body fluids. Choice C is incorrect because viral pneumonia, even with brown sputum, does not require airborne precautions as it is transmitted through respiratory droplets. Choice D is incorrect because advanced carcinoma of the lung with hemoptysis does not require airborne precautions as it is not an airborne transmitted disease.