Reinforcing the dressing would help decrease bleeding

Reinforcing the dressing would help decrease
bleeding, but the nurse must assess first.
4. The client is potentially unstable; therefore,
the nurse should not delegate any care to
the UAP.
Content – Medical/Surgical: Category of Health
Alteration – Musculoskeletal: Integrated Processes –
Nursing Process: Implementation: Client Needs –
Physiological Integrity: Reduction of Risk Potential:
Cognitive Level – Application
MAKING NURSING DECISIONS:
Any time the nurse
receives information from another staff member
about a client who may be experiencing a compli-
cation, the nurse must assess the client. The nurse
should not make decisions about a client’s needs
based on another staff member’s information.
13. 1. Tying a client to a chair is a form of
restraint, and the client cannot be
restrained without an HCP order;
therefore, the nurse should immediately
free the client. This is a legal issue.

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2. The UAP is not hired to smoke with the
client and the nurse should talk to the UAP,
but this does not warrant an immediate
response. The client being illegally re-
strained warrants immediate intervention.
3. Bringing a beverage to the client would not
warrant immediate intervention.
4. The UAP can assist the client to ambulate.
Content – Medical/Surgical: Category of Health
Alteration – Management: Integrated Processes –
Nursing Process: Implementation: Client Needs –
Physiological Integrity: Safety and Infection Control:
Cognitive Level – Application
MAKING NURSING DECISIONS:
Delegation means
the nurse is responsible for the UAP’s actions
and performance. The nurse must correct the
UAP’s performance to ensure the client is cared
for safely and legally in the hospital or the home.
14. 1. Tinea corporis is commonly known as
“ringworm” and should have cool com-
presses applied, not warm compresses.
2. The LPN can apply medication to the
client’s athlete’s foot; therefore, this is
an appropriate assignment for the LPN.
3. Onychomycosis is a fungal infection of the
toenails (crumbly, discolored, and thickened
nails); the HCP, not the UAP, should remove
the toenail.
4. Isotretinoin (Accutane) used to treat acne is
contraindicated in women who are pregnant
or who are intending to become pregnant
while on the drug.
Content – Medical/Surgical: Category of Health
Alteration – Integumentary: Integrated Processes –
Nursing Process: Planning: Client Needs – Safe and
Effective Care Environment: Management of Care:
Cognitive Level – Synthesis
MAKING NURSING DECISIONS:
When the test
taker is deciding which option is the most
appropriate task to delegate/assign, the test
taker should choose the task that allows each
member of the staff to function within his or
her full scope of practice. Do not assign a task
to a staff member that requires a higher level of
expertise than the staff member has.