a patient may need restraints which task can the nurse delegate to a nursing assistive personnel
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Nursing Elites

ATI RN

ATI Capstone Comprehensive Assessment B

1. A patient may need restraints. Which task can the nurse delegate to a nursing assistive personnel?

Correct answer: D

Rationale: The correct answer is applying the restraint (Choice D). Nursing assistive personnel can be delegated the task of applying restraints under the supervision and direction of a nurse. Determining the need for restraints (Choice A) and obtaining an order for a restraint (Choice B) involve clinical judgment and assessment, which are responsibilities of the nurse. Assessing the patient's orientation (Choice C) also requires a level of assessment that should be performed by a nurse.

2. A nurse is assessing a client who is receiving a continuous IV infusion of heparin. Which of the following findings should the nurse report to the provider?

Correct answer: B

Rationale: The correct answer is B. Bruising on the arms and legs is a sign of bleeding, which is a serious complication of heparin therapy and should be reported immediately to the provider. Option A is incorrect as urine output greater than 30 mL/hr is a normal finding. Option C, positive Trousseau's sign, is associated with hypocalcemia, not heparin therapy. Option D, urine output of 60 mL/hr, is within the normal range and does not indicate a complication of heparin therapy.

3. A nurse manager assigns a nursing assistant a task outside of their role. What should the nursing assistant do?

Correct answer: B

Rationale: If a nurse manager assigns a nursing assistant a task that is outside of their role, the nursing assistant should report the task to the charge nurse. This is important because the charge nurse can provide guidance on whether the task is appropriate for the nursing assistant to perform. Choice A is incorrect because blindly following a directive that is outside of the nursing assistant's scope could lead to negative consequences. Choice C might not be the best course of action initially, as it's important to seek clarification first. Choice D is also not the best option because performing a task outside of one's role without proper authorization can pose risks to both the patient and the nursing assistant.

4. A patient is being taught to use TD nitroglycerin patches to treat angina pectoris. What instructions should be included?

Correct answer: B

Rationale: The correct answer is to apply a new patch every morning. Nitroglycerin patches should be applied in the morning and removed at bedtime to provide a 14-hour nitrate-free interval, preventing tolerance development. Choice A is incorrect because applying a patch every 12 hours may lead to tolerance. Choice C is incorrect because nitroglycerin patches are used prophylactically, not just when symptoms appear. Choice D is incorrect because rotating the application site weekly is not necessary; the same site can be used as long as there is no skin irritation.

5. A client is undergoing chemotherapy and expresses concern about hair loss. What is the best response?

Correct answer: D

Rationale: The best response when a client undergoing chemotherapy expresses concern about hair loss is to advise them that chemotherapy causes temporary hair loss. This response provides accurate information to the client about the side effect they are experiencing. Choice A is incorrect because it may provide false reassurance as for some individuals, hair loss can be a challenging experience. Choice B is not the best initial response as addressing the client's concerns and providing information should come first. Choice C is not the most appropriate response as cutting hair short may not necessarily prevent hair loss and does not address the client's concerns about the temporary nature of chemotherapy-induced hair loss.

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