The client with a stroke was admitted to a medical-surgical unit. Which tasks does the nurse delegate to the unlicensed assistive personnel?
a. Complete the nursing care plan.
b. Assist the client with meals.
c. Evaluate the pulse oximetry reading.
d. Assess level of consciousness.
B
The nurse needs to know the five rights of delegation: right task, right circumstances, right person, right communication, and right supervision. Unlicensed assistive personnel can help with feeding, but only the nurse can care plan, assess the level of consciousness, and evaluate the oxygenation of the client.
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A newly diagnosed HIV-positive adolescent has blood work drawn, which includes a CD8 T-cell count. The nurse knows which of the following functions of CD8 T cells listed below will assist the adolescent's immune system in fighting off the viral attack? Se
A) Release destructive enzymes B) Trigger intracellular programmed death C) Cause allergens to surround the virus D) Boost antigen-antibody response E) Remove foreign material from lymph before it enters the blood
An 80-year-old woman who lives alone in a rural area was brought to the clinic by a neighbor after reporting several recent falls
When talking with the nurse she denied any injuries, but said that she recently began to feel dizzy when she gets out of bed or a chair. The nurse is concerned that she may be dehydrated when she notices that the client: (Select all that apply.) 1. Has lost over 8 pounds since last month. 2. Has an increased heart rate. 3. Appears to be slightly confused. 4. Has a lower blood pressure than normal. 5. Has lower extremity edema.
When the 12-year-old with juvenile idiopathic arthritis (JIA) tells the nurse that she is having trouble reading her text books, the nurse examines the child's eyes and assesses nonreactive pupils. The nurse recognizes indications of:
a. Iridocyclitis b. Retinal detachment c. Glaucoma d. Bleeding into the anterior chamber
The client has a large, deep wound on the sacral region. The nurse correctly packs the wound by:
1. Filling two thirds of the wound cavity 2. Leaving saline-soaked folded gauze squares in place 3. Putting the dressing in very tightly 4. Extending only to the upper edge of the wound