Tiêu đề RECALLS 8 - NP3 - SC ✅

Situation: Annaliza, a senior nurse, is reviewing her knowledge regarding delegation and task management. 46. Annaliza, a nurse in a busy Philippine hospital is delegating tasks to a team of nurses and nursing assistants. Which task should she delegate to a nursing assistant? A. Administering intravenous medications B. Performing a comprehensive physical assessment C. Assisting a patient with daily activities and basic care D. Developing a care plan for a complex patient 47. The head nurse is reviewing the delegation process with a new nurse in a hospital in the Philippines. Which of the following principles should the nurse use to ensure effective delegation? A. Delegate tasks that require the nurse’s unique skills to unlicensed personnel B. Ensure that the delegatee has the necessary competence and training for the task C. Delegate all tasks to ensure that the workload is evenly distributed D. Only delegate tasks that are easy and can be done quickly 48. Nurse Annaliza is dealing with a situation where a nursing assistant is frequently late for their shift. What is the most appropriate action for the nurse manager to take? A. Ignore the lateness if it does not affect patient care B. Discuss the issue with the nursing assistant privately and address the pattern of lateness C. Reprimand the nursing assistant publicly to set an example D. Reassign the nursing assistant to a different shift without discussing the issue 49. Nurse Annaliza is preparing to delegate a complex wound dressing change. Which aspect of delegation is critical for ensuring that the task is performed safely? A. Verifying that the task is within the scope of practice for the delegatee B. Delegating the task without providing instructions C. Only providing verbal instructions without written guidelines D. Assuming that the delegatee knows how to perform the task without supervision 50. A nurse manager in the Philippines needs to prioritize tasks for a busy unit. Which of the following tasks should the nurse manager prioritize? A. Completing paperwork for routine audits B. Addressing a sudden change in a patient's condition C. Organizing a staff social event D. Conducting a review of patient satisfaction surveys Situation: A patient arrives at the emergency department accompanied by her son, who reports that about 30 minutes ago, his mother suddenly developed numbness and weakness in her left arm, along with slurred speech, while watching television. She has no history of head trauma. 51. The patient reports numbness and weakness of the left arm and slurred speech. Which nursing intervention is a priority? A. Prepare to administer recombinant tissue plasminogen activator (rt-PA). B. Discuss the precipitating factors that caused the symptoms. C. Schedule for a STAT computed tomography (CT) scan of the head. D. Notify the speech pathologist for an emergency consult. 52. The nurse is assessing a client experiencing motor loss as a result of a left-sided cerebrovascular accident (CVA). Which clinical manifestation would the nurse document? A. Hemiparesis of the client’s left arm and apraxia. B. Paralysis of the right side of the body and ataxia. C. Homonymous hemianopsia and diplopia. D. Impulsive behavior and hostility toward family. 53. The nurse is planning care for a client experiencing agnosia secondary to a cerebrovascular accident. Which collaborative intervention will be included in the plan of care? A. Observe the client swallowing for possible aspiration. B. Position the client in a semi-Fowler’s position when sleeping. C. Place a suction setup at the client’s bedside during meals. D. Refer the client to an occupational therapist for evaluation. 54. The client diagnosed with atrial fibrillation has experienced a transient ischemic attack (TIA). Which medication would the nurse anticipate being ordered for the client on discharge? A. Aspirin B. Timolol C. Heparin D. Streptokinase 55. The resident in a long-term care facility fell during the previous shift and has a laceration in the occipital area that has been closed with steristrips. Which signs/symptoms would warrant transferring the resident to the emergency department? A. A 4-cm area of bright red drainage on the dressing. B. A weak pulse, shallow respirations, and cool pale skin. C. Pupils that are equal, react to light, and accommodate. D. Complaints of a headache that resolves with medication. 56. A client with a stroke is unable to speak but can understand spoken language. Which condition best describes this client’s speech difficulty? A. Receptive aphasia B. Expressive aphasia C. Global aphasia D. Wernicke’s aphasia 57. A patient is given a hairbrush but uses it to brush their teeth instead. This incorrect use of an object demonstrates which condition? A. Ataxia B. Apraxia C. Aphasia D. Agnosia 58. The client is admitted to the medical floor with a diagnosis of closed head injury. Which nursing intervention has priority? A. Assess neurological status. B. Monitor pulse, respiration, and blood pressure. C. Initiate an intravenous access. D. Maintain an adequate airway 59. A patient admitted to the CCU was rushed to the hospital following a myocardial infarction. The patient has a history of hemorrhagic stroke. Which medication order would the nurse question? A. Alteplase (tPA) 15 mg IV bolus, then infusion as per protocol B. Oxygen at 2 L/min via nasal cannula C. Metoprolol 25 mg PO twice daily D. Morphine sulfate 2 mg IV every 2 hours PRN for chest pain Situation: Head injury is trauma to the scalp, skull, or brain from blunt or penetrating forces. It can be open (with fracture/penetration) or closed (without fracture), ranging from mild concussion to severe brain injury, and may lead to complications like increased intracranial pressure, cerebral edema, or secondary injury from hypoxia or hypotension. 60. The client is diagnosed with a closed head injury and is in a coma. The nurse writes the client problem as “high risk for immobility complications.” Which intervention would be included in the plan of care? A. Position the client with the head of the bed elevated at intervals. B. Perform active range-of-motion (ROM) exercises every four (4) hours. C. Turn the client every shift and massage bony prominences. D. Explain all procedures to the client before performing them. 61. An unconscious client with multiple injuries to the head and neck arrives in the emergency department. What should the nurse do first? A. Determine the identity of the client. B. Stop bleeding from open wounds. C. Check for a neck fracture. 4 | Page