Author Question: The nurse is preparing for morning rounds. What should the nurse avoid delegating to unlicensed ... (Read 55 times)

KWilfred · **on:** Jul 23, 2018

The nurse is preparing for morning rounds. What should the nurse avoid delegating to unlicensed assistive personnel?

1. Vital signs
2. Filling of water pitchers
3. Skull and face assessment
4. Ambulation of surgical clients

Question 2

While performing an assessment of the integument system, the nurse notes the client's eyeballs are protruding and the upper eyelids are elevated. What term should the nurse use to document this finding?

1. Erythema
2. Cyanosis
3. Exophthalmos
4. Normocephalic

mjbamaung · **Reply #1 on:** Jul 23, 2018

Answer to Question 1

Correct Answer: 3
Rationale 1: Vital signs can appropriately be delegated to unlicensed assistive personnel.
Rationale 2: Filling of water pitchers can be appropriately delegated to unlicensed assistive personnel.
Rationale 3: Assessment of the skull and face may not be delegated to unlicensed assistive personnel.
Rationale 4: Ambulation of surgical clients can be appropriately delegated to unlicensed assistive personnel.

Answer to Question 2

Correct Answer: 3
Rationale 1: Erythema is a term used to describe redness.
Rationale 2: Cyanosis is a term used to describe a bluish cast to the skin, nails, or mucous membranes.
Rationale 3: Hyperthyroidism can cause exophthalmos, a protrusion of the eyeballs with elevation of the upper eyelids, resulting in a startled or staring expression.
Rationale 4: Normocephalic is a term used to describe a normal sized head.