36: A nurse is delegating care for a group of four clients. Which of the following tasks should the nurse delegate to an assistive person?
Irrigate and perform a dressing change for a client who has a pressure injury wound.
Obtain a daily weight on a client who has heart failure.
Teach the use of an incentive spirometer to a postoperative client.
Administer oral PRN pain medication to a client who has arthritis.
The Correct Answer is B
A. Irrigate and perform a dressing change for a client who has a pressure injury wound: This task requires specialized knowledge and skill, particularly in wound care management. It involves assessing the wound, choosing appropriate dressings, and monitoring for signs of infection, which are beyond the scope of duties for assistive personnel.
B. Obtain a daily weight on a client who has heart failure: This task is suitable for delegation to an assistive person because it is a routine, non-invasive procedure that does not require clinical judgment or assessment. It helps in monitoring the client's condition, especially in heart failure management.
C. Teach the use of an incentive spirometer to a postoperative client: Teaching involves educating the client on the proper technique and benefits of using the device, which requires nursing judgment and the ability to address questions or concerns. This task should be performed by a nurse.
D. Administer oral PRN pain medication to a client who has arthritis: Administering medications involves evaluating the client’s pain level, assessing potential side effects, and ensuring the correct medication is given, which requires a nurse’s clinical judgment and knowledge.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Place the chair at a 90° angle to the bed: Incorrect. The chair should be placed at an angle to facilitate a smoother transfer, usually around 45° to the bed, allowing easier movement from the bed to the chair.
B. Place the chair on the client's left side: Incorrect. The chair should be positioned on the strong side of the client if possible, or the side the client will be transferring towards, not necessarily the left side.
C. Lock the wheels on the client's bed: Correct. Locking the wheels on the bed ensures that the bed remains stationary during the transfer, providing safety and stability for the client.
D. Raise the height of the client's bed: Incorrect. The bed should be adjusted to a height that allows the nurse to safely transfer the client without excessive bending or stretching. However, raising it too high might make it difficult for the nurse to maneuver the client safely.
Correct Answer is B
Explanation
A. Use a square knot. Using a square knot is not recommended for securing restraints because it can be difficult to quickly release in an emergency. Instead, restraints should be secured with a quick-release tie to ensure they can be removed promptly if necessary.
B. Assess the extremity for circulation and neurological integrity every 2 hours. Regular assessment of the extremity is essential to ensure that the restraint is not impairing circulation or causing nerve damage. This frequent monitoring helps prevent complications and ensures the client’s safety.
C. Secure the restraint to the side rail. Securing restraints to the side rail is not recommended as it can cause injury or entrapment. The restraint should be secured to the bed frame or a fixed part of the bed that does not move or pose a risk to the client.
D. Assess restraints and skin integrity every 12 hours. Assessing restraints and skin integrity every 12 hours is inadequate. More frequent assessments, such as every 2 hours, are necessary to prevent skin breakdown and ensure that the restraints are not causing harm.
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