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A registered nurse (RN) is delegating tasks to a licensed practical nurse (LPN) and a certified nursing assistant (CNA). Which statement by the RN demonstrates an appropriate delegation to the CNA, based on scope of practice?

An infant, three weeks old, is admitted to the Emergency Room. The mother reports that the infant has been irritable, difficult to breastfeed and has had diarrhea for the past 4 days. The infant’s respiratory rate is elevated and the fontanels are sunken. The Emergency Room physician orders ABGs after assessing the ABCs.The results from the ABGs come back from the laboratory and show:    pH = 7.37    Pa C02 = 29 mmHg    HC03 = 17 mEq/L What is your interpretion of the ABG results?

The nurse is creating a plan of care to prepare a 56-year-old male patient with ascites for a paracentesis. Which interventions should the nurse include to prep the patient and reduce the risk of complications? (Select all that apply)

The nurse is assessing a patient who sustained a traumatic brain injury. Using the Glasgow Coma Scale (GCS), match each observed patient response with the appropriate GCS component and score.

The nurse received an aPTT report on a client receiving heparin via continuous drip infusion. According to the report, the client’s drip rate should be decreased by 100 units per hour. The heparin comes prepared as 25,000 units in 500 mL of fluid. The current rate of infusion is 26 mL per hour. At what rate should the nurse set the pump?

A client in the immediate postoperative period has the following arterial blood gas (ABG) values: pH: 7.30 PaCO2: 52 mm Hg PaO2: 98 mm Hg HCO3: 22 mEq/L (22 mmol/L) As the nurse, develop a comprehensive plan of care to address the client’s ABG findings and prevent further complications. Prioritize the actions to be implemented immediately. Select all that apply:

A client with a diagnosis of acute coronary syndrome is on a cardiac monitor. The nurse interprets the monitor rhythm to be supraventricular tachycardia at a rate of 150 beats/min. The client is awake and coherent, and oxygen is being administered at a rate of 6 L/min via a nasal cannula. What is the first nursing action?

The nurse understands clamping a chest tube may cause what problem?

A patient reports “feels like my heart is pounding” and shortness of breath. During cardiac monitoring in the emergency department (ED), the nurse obtains the following electrocardiographic (ECG) tracing. The nurse interprets this heart rhythm as

Scenario:A 62-year-old malnourished patient is receiving total parenteral nutrition (TPN) via a central line. During the nurse’s assessment, the following findings are noted: Assessment Findings: Vital Signs: BP: 128/76 mmHg HR: 92 bpm RR: 20 breaths/min Temp: 99.1°F (37.3°C) Laboratory Results: Serum glucose: 280 mg/dL (elevated) Serum potassium: 3.2 mmol/L (low) Serum sodium: 136 mmol/L (normal) Patient Complaints: “I feel really thirsty.” “My mouth feels dry, and my hands are tingling.” Other Findings: TPN is infusing as prescribed at 75 mL/hr. Question Type: Select All That Apply (SATA)Question:Based on the assessment findings, which nursing actions are appropriate to address the patient’s condition?