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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. "The medication may cause ringing in my ears.": Ringing in the ears (tinnitus) is not a common side effect of haloperidol. This statement does not indicate understanding of the medication’s typical side effects.
B. "The medication may cause urinary incontinence.": Urinary incontinence is not a common side effect of haloperidol. This statement is not accurate regarding the medication's effects.
C. "I may be more sensitive to the sun while taking this medication.": This statement indicates understanding, as haloperidol can increase sensitivity to sunlight, making clients more susceptible to sunburn.
D. "I may experience a metallic taste while taking this medication.": A metallic taste is not a common side effect of haloperidol. This statement does not reflect the typical effects of the medication.
Correct Answer is C
Explanation
A. Bronchial airway constriction: In the fight-or-flight response, bronchial airways actually dilate to increase airflow to the lungs, rather than constricting.
B. Hypoglycemia: The fight-or-flight response typically leads to increased blood glucose levels (hyperglycemia) to provide quick energy, not decreased levels.
C. Dilated pupils: During the fight-or-flight response, pupils dilate to improve vision and help the individual better detect threats. This is a classic manifestation of this stress response.
D. Decreased blood pressure: The fight-or-flight response generally increases blood pressure due to the release of adrenaline and other stress hormones that prepare the body for immediate action.
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