NCLEX PN Test Bank - Nurselytic

Correct Answer: D

Rationale: Taking extended lunch breaks is an unacceptable behavior, especially when it affects client care. The appropriate way for the nurse to deal with this situation is to meet with the nursing assistant to discuss the behavior and initiate problem-solving measures. This direct approach allows for open communication and the opportunity to address the issue effectively. Ignoring the situation (
Choice
A), asking other staff members to cover (
Choice
C), or documenting the problem in the nursing assistant's personnel file (
Choice
B) are not effective solutions. Ignoring the behavior does not address the issue, asking others to cover may not solve the problem at its root, and documenting the problem should come after attempting to resolve the issue through communication and problem-solving first.

Correct Answer: D

Rationale: If the client develops signs or symptoms of autonomic dysreflexia, they need to be addressed immediately. If the family member is not able to relieve them, a healthcare provider needs to be notified immediately. The statement 'I should observe whether symptoms worsen' indicates a passive approach and does not address the urgency of the situation.

Choices A, B, and C are correct as they involve active measures to address autonomic dysreflexia, such as raising the client to a sitting position, checking for a fecal impaction, and looking for a kink in the urinary catheter tubing.

Correct Answer: D

Rationale: The correct answer is 'Hispanic.' Hispanic individuals in the United States are at a higher risk for pesticide-related injuries due to their representation among migrant workers in agricultural settings. This exposure to pesticides in their work environments increases their risk compared to other ethnic groups.
Choice A, 'Native American,' although indigenous populations may face environmental health disparities, the higher risk in this context is among Hispanic individuals.
Choice B, 'Asian-Pacific,' and
Choice C, 'Norwegian,' do not have the same level of exposure to pesticides as Hispanic migrant workers, making them less susceptible to pesticide-related injuries.

Correct Answer: C

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.

Correct Answer: D

Rationale: When delegating tasks, a nurse must consider the staff member's education and competency level. Noninvasive tasks like helping a client ambulate with a walker are usually suitable for nursing assistants. Suctioning a client and colostomy irrigation are invasive procedures that require a licensed nurse's skills. Assessing a client post-arteriogram for any complications or changes in condition also necessitates the expertise of a licensed nurse.
Therefore, the most appropriate task to assign to a nursing assistant is assisting a client who needs frequent ambulation with a walker.