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.

Answer and Explanation

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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Correct Answer is C

Explanation

A. Acute pain manifested by client's report: While this diagnosis reflects the client's report of pain, it does not address the underlying cause or etiology of the pain, which is important for forming an effective care plan.
B. Acute pain related to psychosomatic condition: This diagnosis implies a specific psychosomatic origin for the pain. Since the etiology is unknown, attributing it to a psychosomatic condition may not be accurate.
C. Acute pain related to unknown etiology: This diagnosis is the most appropriate because it acknowledges the presence of acute pain and explicitly notes that the cause is unknown, which aligns with the information provided.
D. Acute pain related to unknown factors: This diagnosis is similar to C, but "unknown factors" is less precise than "unknown etiology." The term "etiology" more accurately describes the underlying cause.

A. The client will teach back information about safe crutch walking on day 1. B. The client will demonstrate safe crutch walking. C. The client will not lean on the crutches to support their body weight. D. The client will ambulate 5 feet in one day. E. The client will walk 10 feet by day 2. F. The client will walk 20 feet by day 3. G. The client will explain 4 principles of crutch safety. H. The client will explain how to keep crutches in safe condition.

Correct Answer is ["A","D","E","F"]

Explanation

A. The client will teach back information about safe crutch walking on day 1: This goal includes a specific time frame ("on day 1") which makes it a timed component. It establishes when the client is expected to demonstrate understanding, aligning with the SMART criteria for setting time-specific goals.

B. The client will demonstrate safe crutch walking: While this goal describes a desired outcome, it does not include a time frame, so it lacks the timing component needed for SMART criteria.

C. The client will not lean on the crutches to support their body weight: This goal focuses on the behavior change but does not specify when this should be achieved, missing the timed element of SMART goals.

D. The client will ambulate 5 feet in one day: This goal has a specific time frame ("in one day"), indicating when the client should achieve the goal, which is a critical aspect of SMART outcomes.

E. The client will walk 10 feet by day 2: This goal includes a specific time frame ("by day 2"), providing a clear deadline for achieving the goal, which is essential for SMART objectives.

F. The client will walk 20 feet by day 3: This goal includes a specific time frame ("by day 3"), which provides a deadline for reaching the goal, meeting the criteria for SMART goals.

G. The client will explain 4 principles of crutch safety: This goal describes an outcome but does not include a time frame, so it lacks the timed aspect necessary for SMART goals.

H. The client will explain how to keep crutches in safe condition: This goal focuses on an outcome without specifying a deadline, thus missing the timed component required for SMART goal setting.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is providing care to a client that has been having pain without a clear etiology. Which nursing diagnosis should the nurse write as most appropriate for this client?

Correct Answer is C

Explanation

Correct Answer is ["A","D","E","F"]

Explanation

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