NR-446 Collaborative Healthcare - Set 2 - Part 3

Correct Answer: Assisting a stable client to the chair for breakfast

Helping a stable client into a chair is routine mobility work within the training of assistive personnel and requires no nursing judgment. Handing it off frees the nurse for the client who is deteriorating. Option a is incorrect because initial client education belongs to the registered nurse and may never be transferred to unlicensed staff. Teaching demands assessment of readiness and evaluation of understanding, neither of which assistive personnel can perform. Option c is incorrect because a burning intravenous site needs a nursing assessment to distinguish infiltration from phlebitis and to decide whether the line comes out. Unlicensed staff may report what they see but may not interpret it. Option d is incorrect because judging the effect of a medication is the evaluation step of the nursing process. A helper can bring the nurse a pain rating, yet the conclusion drawn from it stays with the nurse.

Correct Answer: A client whose drain output rose sharply with a rising pulse

A sudden rise in drain output together with a climbing pulse points to active bleeding, and tachycardia appears before the blood pressure falls. Circulation problems that are progressing take precedence over the other three findings. Option b is incorrect because moderate pain that has not fully resolved calls for reassessment and possibly a different approach, but it sits at the second level of priority behind a client who may be hemorrhaging. Option c is incorrect because diminished bowel sounds belong to the ordinary picture after abdominal surgery, when anesthesia and handling of the bowel slow motility. The finding is monitored rather than treated as urgent. Option d is incorrect because concentrated urine suggests a fluid volume deficit that the nurse addresses with intake, and it identifies a hydration problem rather than an emergency. Nothing here is changing minute to minute.

Correct Answer: Chart soon after each intervention is completed

Charting as soon as possible after an intervention keeps the record accurate and makes the information available to the rest of the team. Deferred documentation loses detail, adds omissions, and pushes the nurse past the end of the shift. Option a is incorrect because charting while moving divides attention between two demanding activities. Attention does not split; it switches, and each switch costs accuracy, which is how identifiers and reassessment findings get dropped from a record. Option c is incorrect because compressing a whole shift into the last hour is the very pattern the manager is trying to change. It guarantees the late departure and leaves the team without current information all day. Option d is incorrect because recall degrades quickly across a twelve-hour assignment. A single summary written from memory blurs times, doses, and responses, producing a record that is shorter to write and far less defensible afterward.

Correct Answer: Delegate the discharge transport and room preparation

The admission assessment and the discharge teaching both require the registered nurse. Handing off transport of a stable client and preparation of the room moves those tasks to assistive personnel and returns time to the nurse. Option a is incorrect because the admission assessment is a nursing process step reserved to the registered nurse. A practical nurse collects data and reports it, and the interpretation that turns those findings into a plan cannot be handed over. Option b is incorrect because unlicensed staff never provide client education, discharge instruction included. Teaching requires assessing what the client already knows and evaluating whether the new information was understood, and neither of those belongs outside the nurse's role. Option c is incorrect because stalling the admission leaves a client waiting in the emergency department without a nursing assessment. Reorganizing the shift means moving delegable work to others, not queuing two urgent obligations behind one another.

Correct Answer: Observe the transfer directly at the bedside

Direct supervision means the nurse is present and watching as the activity occurs. A newly hired worker, an unvalidated skill, and a first postoperative transfer together raise the harm potential, so oversight is titrated upward to direct observation. Option a is incorrect because reading documentation afterward is indirect supervision, which suits an experienced worker doing a routine task on a stable client. Here the record would only confirm what already happened, including a fall. Option b is incorrect because being reachable is not the same as being present. Phone availability helps only if the worker recognizes trouble and calls, and a worker new to this transfer may not recognize it in time. Option d is incorrect because a later conversation with the client evaluates an outcome rather than monitoring performance. Supervision of an unproven skill has to happen while the movement is under way, when the nurse can still intervene.

Correct Answer: Go assess the client at the bedside

The personnel measured and reported correctly; interpretation belongs to the nurse. A drop in pressure with new lightheadedness requires direct assessment before any other step, because a change in condition is never managed from secondhand data. Option b is incorrect because a repeat number from the same unlicensed source adds no judgment. Rechecking may follow the nurse's own examination, but sending someone else back delays the assessment the symptom already warrants. Option c is incorrect because calling on secondhand information leaves the nurse unable to answer the questions that follow. The provider will want the current examination, the trend, and the client's appearance, none of which the nurse has yet. Option d is incorrect because charting is a record of what was found, not a response to it. Deferring the visit while symptoms are present converts a reported change into an unwitnessed one.

Correct Answer: Right circumstance, because this client is not stable

Vital signs are a legitimate delegated task, but naloxone has a shorter duration than many opioids, so this client may become sedated again. An unstable client makes the circumstance wrong regardless of the task. Option a is incorrect because measuring vital signs sits within the assistive personnel job description and needs no license. The activity itself is delegable, and the client's shifting condition is what disqualifies it here. Option c is incorrect because nothing in the situation suggests this worker was never trained on taking vital signs. Right person turns on scope, validated competence, and capacity, none of which is in question. Option d is incorrect because supervision is the last right checked, and the checklist stops at the first failure. Vague wording also weakens the direction, yet the client's instability comes earlier in the sequence.

Correct Answer: Start chest compressions and send the coworker for help

Pulseless apnea is cardiac arrest, and compressions restore some circulation to the brain and heart within seconds. Sending the coworker for the code team gets help moving while the nurse keeps perfusion going. Option a is incorrect because vital signs add nothing once absence of a pulse and absence of breathing have already been established. Gathering more data here only delays the one action that changes the outcome. Option b is incorrect because resuscitation begins immediately unless a valid do not resuscitate order is already known to the team. Chart review during an arrest costs minutes the client's brain does not have. Option c is incorrect because charting is the last step of any emergency and never the first. Times and events are recorded accurately after the resuscitation, most often by a designated recorder rather than the responding nurse.

Correct Answer: Assignment of work already within each nurse's scope

Distributing clients whose care already falls within each nurse's authorized scope is an assignment. The work is theirs by license and job description, so no separate transfer of a specific task occurs. Option b is incorrect because delegation moves authority for one discrete task, such as a single glucose check, rather than a whole caseload. Nothing here is being handed across a scope boundary. Option c is incorrect because supervision happens after work is distributed, when the charge nurse monitors and evaluates how the care is being carried out. Distributing the clients is the earlier step. Option d is incorrect because no competence appraisal is described here. Judging a nurse's ability is part of preparing an assignment and of ongoing performance review, not the act of dividing the caseload.

Correct Answer: Nominal group technique with private ranking

Nominal group technique has members write ideas silently, share them round robin without discussion, then rank privately. The structure gives every member equal weight and is the direct remedy for domination by a few voices. Option a is incorrect because brainstorming generates a long list quickly but leaves the floor open, so the loudest voices still set the direction and anchor the group on whatever idea is offered first. Option b is incorrect because a show of hands is fast and transparent, yet it creates a losing minority and suppresses the very information the quiet members hold. It also produces no ideas at all. Option d is incorrect because consensus builds strong commitment to implementation but relies on continued open discussion, which is exactly where senior or forceful members dominate the room and the quiet nurses stay quiet.