HESI BSN395 Compass Exit Exam
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Free HESI BSN395 Compass Exit Exam Questions
An older adult female asks the clinic nurse about getting a herpes vaccination because she gets cold sores on her mouth when she is sick or stressed. How should the nurse respond?
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Describe the use of the vaccination to treat herpes simplex type 2.
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Confirm that a consent form is signed before administering the vaccination.
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Explain the use of the vaccination to reduce risk for herpes zoster.
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Arrange for skin testing to evaluate if the client is a candidate for the vaccine.
Explanation
The herpes vaccine available (such as Shingrix) is designed to prevent herpes zoster (shingles), which is caused by the reactivation of the varicella-zoster virus, not herpes simplex. The client's cold sores are caused by herpes simplex virus type 1 (HSV-1), for which there is no available vaccine. The nurse should clarify this distinction and educate the client about what the herpes vaccination actually protects against.
Why the other options are incorrect:
A. Describe the use of the vaccination to treat herpes simplex type 2 — The available herpes vaccine does not treat or prevent herpes simplex type 2. It targets herpes zoster. Additionally, vaccines prevent disease; they do not treat existing infections.
B. Confirm that a consent form is signed before administering the vaccination — This step is premature. The nurse must first educate the client about what the vaccine does and does not cover before any administration is considered.
D. Arrange for skin testing to evaluate if the client is a candidate for the vaccine — Skin testing is not a requirement or standard step in determining candidacy for the herpes zoster vaccine.
A nurse at the community senior center is looking to initiate better ways to support seniors. The nurse mentions the importance of the Four Ms. Which are the appropriate steps of the Four Ms? Select all that apply.
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What matters.
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Mentation.
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Motivation.
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Mobility.
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Medication.
Explanation
Correct Answer: (A) What matters, (B) Mentation, (D) Mobility, and (E) Medication.
The Four Ms is an evidence-based framework developed for Age-Friendly Health Systems to guide the care of older adults. Each component addresses a critical aspect of senior health and wellbeing.
What matters refers to understanding and respecting each older adult's specific health outcome goals, care preferences, and what is most important to them in their daily life and healthcare decisions.
Mentation refers to preventing, identifying, treating, and managing dementia, depression, and delirium in older adults, as cognitive and mental health are central to overall wellbeing and quality of life in the senior population.
Mobility refers to ensuring older adults move safely every day to maintain function, prevent falls, avoid complications of immobility, and support independence in daily activities.
Medication refers to reviewing and managing medications carefully in older adults, using only medications that do not interfere with what matters, mentation, and mobility, and deprescribing those that may cause harm or are no longer appropriate.
Why Other Options are Incorrect:
C. Motivation. Motivation is not one of the Four Ms of the Age-Friendly Health Systems framework. While motivation is an important concept in health promotion generally, it is not a designated component of this specific evidence-based model for senior care.
A heparin infusion is prescribed for a client who weighs 220 pounds. After administering a bolus dose of 80 units/kg, the nurse calculates the infusion rate for the heparin solution at 18 units/kg/hour. The available solution is "Heparin Sodium 25,000 Units in 5% Dextrose Injection 250 mL." The nurse should program the infusion pump to deliver how many mL/hour? (Enter numeric value only. If rounding is required, round to the nearest whole number.)
Explanation
Correct Answer: 18 mL/hour
Step 1 — Convert weight: 220 lbs ÷ 2.2 = 100 kg
Step 2 — Calculate infusion dose: 18 units/kg/hour × 100 kg = 1,800 units/hour
Step 3 — Calculate concentration: 25,000 units ÷ 250 mL = 100 units/mL
Step 4 — Calculate infusion rate: 1,800 units/hour ÷ 100 units/mL = 18 mL/hour
5-Alpha-reductase inhibitors such as finasteride and dutasteride work by blocking the conversion of testosterone to dihydrotestosterone (DHT), which is the androgen responsible for driving prostate tissue growth. By reducing DHT levels, these medications shrink the prostate over time and are indicated for long-term management of benign prostatic hyperplasia (BPH) with an enlarged prostate.
Phosphodiesterase-5 inhibitors such as tadalafil are contraindicated in clients taking nitrates including nitroglycerin because both drug classes cause vasodilation through different mechanisms, and their combination produces a profound and potentially fatal drop in blood pressure. This client takes nitroglycerin as needed for angina, making phosphodiesterase-5 inhibitors contraindicated for him.
Alpha-adrenergic blockers such as tamsulosin and alfuzosin work by blocking alpha-1 adrenergic receptors in the smooth muscle of the prostate and bladder neck, causing relaxation of these muscles and increasing urine flow and ease of urination. They do not reduce prostate size but provide symptomatic relief by relaxing the outlet obstruction.
Alpha-adrenergic blockers, particularly tamsulosin, belong to the sulfonamide chemical class and should be used cautiously in clients with sulfa drug allergies due to the potential for cross-reactivity. This client has a documented allergy to sulfa drugs, making this consideration especially important for this specific client.
Alpha-adrenergic blockers cause systemic vasodilation in addition to their effects on the prostate, which can result in orthostatic hypotension, particularly after the first dose. Clients must be counseled to rise slowly from sitting or lying positions and to take the first dose at bedtime to minimize fall risk.
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The volume of ejaculation may be decreased.
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There is an increase in the risk of cancer.
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Libido may decrease due to usage of this drug.
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Direct contact with this drug can impact a fetus.
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Avoid donating blood while taking this medication.
Explanation
Direct contact with 5-alpha-reductase inhibitors such as finasteride or dutasteride can cause serious harm to a developing male fetus by inhibiting the conversion of testosterone to dihydrotestosterone, which is essential for the normal development of male external genitalia. Pregnant women or women of childbearing age must never handle crushed or broken tablets, and men taking these medications must be counseled accordingly. This is a critical safety consideration that must be prioritized in client teaching.
Men taking 5-alpha-reductase inhibitors must not donate blood during treatment and for a specific period after stopping the medication, typically 6 months for finasteride and 6 months for dutasteride. This is because donated blood could be transfused to a pregnant female recipient, and the drug present in the blood could harm a male fetus. This is an important and often overlooked safety consideration that requires priority education.
Why the other options are incorrect:
Decreased ejaculation volume is a known side effect of 5-alpha-reductase inhibitors but is not a priority safety consideration compared to teratogenicity and blood donation restrictions. It affects quality of life but does not pose a serious safety risk.
The claim that there is an increase in the risk of cancer with 5-alpha-reductase inhibitors is a nuanced topic. While clinical trials showed a small increase in the detection of high-grade prostate cancer in clients taking finasteride, the overall evidence does not establish that these medications cause prostate cancer. This is not the priority teaching consideration for this client.
Decreased libido is a recognized side effect of 5-alpha-reductase inhibitors but, like decreased ejaculation volume, it is a quality-of-life concern rather than a critical safety priority compared to fetal exposure risk and blood donation restrictions.
The nurse observes a decrease in a client's level of consciousness. Which vital sign should the nurse obtain first?
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Temperature.
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Respiratory rate.
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Pulse rate.
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Blood pressure.
Explanation
Correct Answer: (B) Respiratory rate.
When a decrease in level of consciousness is observed, the respiratory rate is the first vital sign the nurse should obtain. Decreased consciousness can indicate respiratory compromise, hypoxia, or neurological deterioration, all of which can rapidly affect breathing. Airway and breathing are always the first priorities in any clinical deterioration. Assessing respiratory rate and adequacy of breathing allows the nurse to determine if immediate airway intervention is required before proceeding with other assessments.
Why Other Options are Incorrect:
A. Temperature. While temperature assessment is important for identifying infection or thermoregulatory issues, it is not the first priority when a client's level of consciousness suddenly decreases. Temperature changes do not pose an immediate life threat in the same way that respiratory compromise does.
C. Pulse rate. While pulse rate is an important cardiovascular assessment, airway and breathing take precedence over circulation in the priority of assessment. Respiratory status must be confirmed first before assessing the circulatory system.
D. Blood pressure. Blood pressure assessment is important for identifying hemodynamic instability, however it is not the first vital sign to obtain when decreased consciousness is observed. Respiratory status is assessed first as hypoxia from inadequate breathing is the most immediately life-threatening cause of altered consciousness.
When performing suctioning for a client with a tracheostomy, which action should the nurse include?
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Apply a water soluble lubricant to the catheter.
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Instruct the client to cough as the suction tip is removed.
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Instill 3 mL of 0.9% sodium chloride before suctioning.
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Wear protective goggles while performing the procedure.
Explanation
Tracheostomy suctioning is an aerosol-generating procedure that poses a significant risk of splashing or spraying respiratory secretions, blood-tinged mucus, or other bodily fluids toward the nurse's face and eyes. Wearing protective goggles or a face shield is a standard precaution required during tracheostomy suctioning to protect the nurse's mucous membranes from exposure to potentially infectious respiratory secretions. This is consistent with standard precautions and infection control guidelines that apply to any procedure with a risk of splash or spray of bodily fluids.
Why the other options are incorrect:
Applying a water soluble lubricant to the suction catheter is not a standard or recommended practice for tracheostomy suctioning. Lubrication is used for nasopharyngeal or nasotracheal suctioning to facilitate passage through the nares, but it is not required or recommended for tracheostomy suctioning where the catheter is inserted directly through the stoma.
Instructing the client to cough as the suction tip is removed is not a standard component of tracheostomy suctioning technique. While encouraging coughing can help mobilize secretions before suctioning, instructing the client to cough specifically as the suction tip is being removed is not part of the evidence-based procedure and could cause trauma to the tracheal mucosa.
Instilling 3 mL of 0.9% sodium chloride before suctioning was a historical practice believed to thin secretions and facilitate their removal. However, current evidence-based guidelines no longer recommend routine saline instillation before tracheostomy suctioning because research has shown it does not effectively thin secretions, can cause oxygen desaturation, increases the risk of infection by introducing organisms into the lower airway, and can cause patient discomfort and distress.
A client in labor begins bleeding profusely from the vagina. Which findings should the nurse report to the healthcare provider?
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Mild discomfort and elevated blood pressure.
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Sharp fundal pain and uterine tenderness.
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Pain in lower quadrant and oliguria.
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Increase in pulse and fetal rate reactivity.
Explanation
Correct Answer: (B) Sharp fundal pain and uterine tenderness
Profuse vaginal bleeding in a client in labor is a serious obstetric emergency. Sharp fundal pain and uterine tenderness are classic signs of abruptio placentae (placental abruption), a condition where the placenta prematurely separates from the uterine wall. This is a life-threatening emergency for both the mother and fetus and must be reported to the healthcare provider immediately. The sharp fundal pain occurs because blood accumulates behind the placenta, causing uterine irritability and rigidity, while uterine tenderness reflects the inflammatory and hemorrhagic process occurring within the uterus.
Why Other Options Are Incorrect:
Mild discomfort and elevated blood pressure are more consistent with preeclampsia rather than an acute hemorrhagic emergency. While elevated blood pressure warrants monitoring, it does not represent the most urgent finding associated with profuse vaginal bleeding requiring immediate reporting.
Pain in the lower quadrant and oliguria may indicate urinary complications or other obstetric issues but are not the hallmark signs of the most likely cause of profuse vaginal bleeding in labor, which is placental abruption.
An increase in pulse is a nonspecific sign of hemorrhage but fetal rate reactivity indicates fetal well-being rather than distress. In a true hemorrhagic emergency such as placental abruption, the fetal heart rate would more likely show signs of distress such as late decelerations or bradycardia, not reactivity.
Nurses' Notes:
1020: Client arrives at the emergency department (ED) and is placed in an exam room. History and assessment, including vital signs, are completed. Reports tightness in her lower left leg and a 1 day history of not feeling well with generalized muscle aches. An assessment of the left lower leg finds it to be red, warm, and swollen starting at the ankle and outer aspect of the foot. A small scab is noted above the lateral ankle. Client reports having a small cut when shaving her legs earlier in the week. Bilateral toes are cool to touch. The left calf temperature is warmer than the right but cooler than the upper extremities.
1030: A capillary blood glucose level is obtained. IV access is established in the left antecubital, and laboratory specimens are collected.
Laboratory Results:
Glucose result is 252 mg/dL (13.9 mmol/L), with a reference range of 74 to 106 mg/dL (4.1 to 5.9 mmol/L), indicating a critically elevated blood glucose level.
Flow Sheet:
1000 — Vital Signs: Temperature 100.5°F (38°C) orally, heart rate 88 beats/minute, respiratory rate 20 breaths/minute, blood pressure 122/72 mm Hg, oxygen saturation 98% on room air, pain 2 on a 0 to 10 scale with bilateral lower legs described from neuropathy and tightness in left calf, weight 284 lb (129.1 kg), height 5 ft 2 in (157.48 cm), body circumference right calf 16.5 in (41.9 cm) and left calf 17.25 in (43.8 cm), capillary refill greater than 3 seconds bilateral lower extremities.
Orders:
1030: Obtain capillary blood glucose level, establish peripheral IV access, obtain two sets of peripheral blood cultures, obtain serum white blood count and lactate.
Question: Choose the most likely options for the information missing from the statements by selecting from the lists of options provided.
Based on the client's history, physical and laboratory findings, the priority need will be to treat ___. In addition, the client will need interventions to manage complications, especially ___ and ___.
Dropdown 1 options: infection, hyperglycemia, kidney disease, congestive heart failure
Dropdown 2 options: osteomyelitis, necrotizing fasciitis, arterial ulcer
Dropdown 3 options: sepsis, diabetic ketoacidosis, hypertension, pressure injury
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infection
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hyperglycemia
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kidney disease
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congestive heart failure
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osteomyelitis
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necrotizing fasciitis
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arterial ulcer
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sepsis
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diabetic ketoacidosis
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hypertension
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pressure injury
Explanation
The priority need will be to treat infection. In addition, the client will need interventions to manage complications, especially sepsis and hyperglycemia
The priority need is to treat infection because all of the client's acute assessment findings, including the red, warm, and swollen left lower leg, the low-grade fever of 100.5°F, the break in skin from shaving, generalized muscle aches, and the orders for blood cultures and lactate levels, collectively point to an active bacterial skin infection (cellulitis) as the primary diagnosis requiring immediate treatment. In a diabetic client with peripheral vascular disease, stage 3a kidney disease, and heart failure, an untreated skin infection carries a very high risk of rapidly progressing to life-threatening complications.
Sepsis is the most urgent and life-threatening complication requiring active prevention and monitoring in this client. The combination of a confirmed infection source, fever, generalized muscle aches, elevated blood glucose, and orders for blood cultures and serum lactate all suggest the clinical team is already concerned about sepsis progression. In a client with multiple immunocompromising comorbidities including diabetes, peripheral vascular disease, and kidney disease, bacteria from the skin infection can enter the bloodstream and trigger a systemic inflammatory response, making sepsis the priority complication to manage.
Hyperglycemia is the second critical complication requiring management because the client's blood glucose of 252 mg/dL is significantly elevated above the normal range. Uncontrolled hyperglycemia impairs neutrophil function, reduces the immune response, slows wound healing, and worsens the severity of the infection. Managing blood glucose aggressively is essential to support the client's ability to fight the infection and prevent further deterioration.
Why the other options are incorrect:
Hyperglycemia as the primary priority is incorrect because while it is a serious concurrent problem, the active infection with its risk of progressing to sepsis represents a more immediately life-threatening emergency that must be treated first.
Kidney disease is a pre-existing chronic condition in this client's medical history rather than an acute complication arising from the current presentation. While the nurse must be mindful of the client's stage 3a kidney disease when administering medications and IV fluids, it is not the priority treatment need for this visit.
Congestive heart failure is also a pre-existing chronic condition and is not the acute problem being addressed in this emergency department visit. There are no findings in the current assessment suggesting an acute exacerbation of heart failure.
Osteomyelitis is a bone infection that can develop as a complication of cellulitis in diabetic clients, particularly with deep tissue involvement. However, there is no current evidence in the assessment findings of bone involvement, making it a potential long-term complication rather than an immediate priority complication to manage at this time.
Necrotizing fasciitis is a rapidly progressing deep tissue infection that is a serious potential complication of cellulitis, but the current assessment does not show signs of necrotic tissue, rapidly spreading infection beyond the skin, or crepitus, making it less immediately supported by the current findings than sepsis.
Arterial ulcer is related to peripheral arterial disease and poor circulation, which this client does have given her peripheral vascular disease history. However, the current presentation is an acute infection from a skin break rather than an ischemic ulcer, and arterial ulcer is not an immediate complication of the current infectious process.
Diabetic ketoacidosis is a complication of severely uncontrolled type 1 diabetes or end-stage type 2 diabetes. While the client has elevated blood glucose, there are no findings such as fruity breath, ketones in urine, or pH changes suggesting DKA is developing, making it a less appropriate complication to prioritize compared to sepsis.
Hypertension is a pre-existing condition in this client's history and the current blood pressure of 122/72 mm Hg is within an acceptable range, meaning hypertension is not an acute complication requiring immediate management during this visit.
Pressure injury is a skin breakdown condition associated with immobility and is not related to the current presentation of cellulitis from a skin break during shaving.
Nurses' Notes:
POD 2 (0845): Client tolerated the surgical procedure well and has been stable since surgery.
POD 3 (0700): Is postoperative below-the-knee amputation right leg day 3. He is sitting up with his left leg and right leg residual limb hanging off the bed. There is patient-controlled analgesia (PCA) of morphine on demand in the left hand area; there is no redness at the site with 0.9% sodium chloride infusing at 50 mL/hr.
Assessment: General: Alert, oriented to person, place, time, and situation. Eyes: Pupils equal, round, reactive to light accommodation (PERRLA). Lungs: Lungs clear all lobes. Heart: Telemetry monitor displaying normal sinus rhythm (NSR). Abdomen: Abdomen soft, bowel sounds in all 4 quadrants. Denies pain with urination and describes urine as light yellow. Right leg: Right leg incision is open to air, skin to the area is cool to touch, and edema noted along the incision. Sutures intact, no redness noted, popliteal pulses strong bilaterally and wound drain with approximately 100 mL red drainage present right leg. Reports pain is a 2 on a 0 to 10 scale, right residual limb area. Left leg: 2+ pedal pulse, loss of hair on the lower leg, skin is dry, scaly, cool to touch, thickened toenails noted, and capillary refill is greater than 4 seconds.
Flow Sheet POD 3 (0700): Temperature: 98.2°F (36.7°C) orally Heart rate: 88 beats/minute normal sinus rhythm (NSR) Respirations: 20 breaths/minute Blood pressure: 126/84 mm Hg Oxygen saturation: 95% on room air Pain: 2 on a 0 to 10 scale, right leg incisional area
Orders (Admit 0845): Leave incision open to air Clean residual limb twice daily with 4 by 4's moistened with 0.9% sodium chloride and pat dry Right residual limb to lie flat in bed Prone position 2 times daily for 30 minutes Atenolol 50 mg PO twice daily Lovastatin 20 mg PO with evening meal Enoxaparin 40 mg subcutaneous every morning Penicillin 500 mg IV piggyback (IVPB) every 6 hours Incentive spirometer Out of bed with assistance by physical therapy (PT) twice daily Laboratory: complete blood count (CBC) with differential, basic metabolic panel, partial prothrombin time (PTT) Low sodium diet Infuse 0.9% sodium chloride IV at 50 mL/hour Patient-controlled analgesia (PCA) settings
The client is at risk for which of the following? Select 3.
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Neuroma
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Contractures
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Deep vein thrombosis
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Atelectasis
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Infection
Explanation
Correct Answer: (A) Neuroma, (B) Contractures, and (C) Deep vein thrombosis
Neuroma is a well-recognized complication following amputation. When peripheral nerves are severed during surgery, the cut nerve endings can form a painful mass of nerve tissue called a neuroma at the residual limb site. This can cause significant pain and complications with prosthetic fitting.
Contractures are a major risk in postoperative amputation clients, particularly when the residual limb is not properly positioned. The nurse's notes already identified that the client's residual limb was hanging off the bed rather than lying flat as ordered, which directly increases the risk of hip or knee flexion contractures that can severely impair prosthetic rehabilitation.
Deep vein thrombosis is a significant postoperative risk due to immobility, surgical trauma, and the client's underlying peripheral vascular disease. The orders include enoxaparin 40 mg subcutaneous every morning, confirming that DVT prophylaxis has been recognized as a priority for this client.
Why Other Options are Less Priority in this Context:
D. Atelectasis While atelectasis is a general postoperative risk due to shallow breathing and immobility, the client's lungs are currently clear in all lobes and an incentive spirometer has been ordered, meaning this risk is being actively managed and is not among the top three specific risks associated with amputation.
E. Infection While infection is always a concern postoperatively, the client is currently receiving Penicillin 500 mg IVPB every 6 hours as prophylaxis, and the wound assessment shows sutures intact with no redness, making it a managed rather than immediate prominent risk compared to the amputation-specific complications listed above.
A client on the unit is scheduled for weighing. The nurse asks an unlicensed assistant to weigh a client. The assistant acknowledges and accepts the assignment. The nurse six hours later reviews the client's record and notes a 4.2 kg difference in weight from the previous day. The nurse should be most concerned with which right of delegation?
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Supervision.
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Direction/communication.
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Person.
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Circumstance.
Explanation
The right of circumstance requires the nurse to ensure that the conditions and environment are appropriate for the delegated task to be carried out safely and accurately. A 4.2 kg weight difference in one day is a clinically significant and unlikely finding that suggests the task was not performed under appropriate circumstances, such as using a properly calibrated scale, weighing at the correct time, or following the correct procedure. The nurse failed to verify that the circumstances were suitable for accurate weight measurement.
Why the other options are incorrect:
A. Supervision — Supervision involves monitoring the performance of the delegated task. While supervision is relevant, the more specific concern here is whether the right conditions were in place for the task to be done correctly, which points to circumstance.
B. Direction/communication — Direction and communication refer to providing clear instructions about how the task should be performed. The question does not indicate that unclear instructions were the issue, making this a less specific concern than circumstance.
C. Person — The right of person refers to ensuring the task is delegated to someone competent to perform it. There is no indication that the UAP lacked the competency to weigh a client, making this the least applicable right in this scenario.
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