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 A
Explanation
A. Orthostatic hypotension increases a client's risk of a fall: Correct. Orthostatic hypotension can lead to dizziness or lightheadedness when standing, increasing the risk of falls.
B. Orthostatic hypotension is indicated by a decrease in systolic blood pressure of 10 mm Hg: This is not specific enough. Orthostatic hypotension is typically defined by a decrease in systolic blood pressure of 20 mm Hg or more when standing.
C. Orthostatic hypotension increases a client's risk of a pulmonary emboli: This is not directly related. Orthostatic hypotension mainly affects balance and fall risk, not the risk of pulmonary emboli.
D. Orthostatic hypotension is indicated by a decrease in diastolic blood pressure of 5 mm Hg: This is incorrect. Orthostatic hypotension is more commonly assessed by a significant drop in systolic blood pressure rather than diastolic pressure.
Correct Answer is D
Explanation
A. "Advance the cane 12 inches forward when walking." Advancing the cane 12 inches forward is not practical; the cane should be moved in a manner that aligns with the client's steps for better balance and support. The movement of the cane should be synchronized with the client's stride rather than a fixed distance.
B. "Keep the cane at the same level as the affected leg when climbing stairs." When climbing stairs, the cane should be held on the side of the unaffected leg to provide optimal support and balance. Keeping the cane level with the affected leg is incorrect and does not provide adequate support.
C. "Hold the cane on the side of your affected leg when walking." The cane should be held on the side opposite the affected leg to provide better stability and support. Holding the cane on the affected side would not offer the necessary support for effective ambulation.
D. "Move your unaffected leg before your affected leg when walking." This is the correct technique as it ensures better balance and stability. Moving the unaffected leg first while using the cane allows for a more secure and coordinated gait, reducing the risk of falls.
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