A charge nurse in a long-term care unit is planning care for a group of clients. Which of the following care tasks should the nurse plan to delegate to an assistive personnel?
Evaluating the effectiveness of acetaminophen administered 30 min ago to a client who reported a headache
Discussing upcoming dietary changes with a client who has a new prescription for a low-cholesterol diet
Measuring urine output every 2 hr for a client recently diagnosed with a urinary tract infection
Inserting a temporary nasogastric tube for a client who has a prescription for laboratory analysis of stomach contents
The Correct Answer is C
A. Evaluating the effectiveness of acetaminophen administered 30 min ago to a client who reported a headache: Assessing medication effectiveness requires professional judgment to evaluate pain relief, side effects, and changes in condition. This is within the registered nurse’s scope of practice and cannot be delegated to an assistive personnel (AP).
B. Discussing upcoming dietary changes with a client who has a new prescription for a low-cholesterol diet: Teaching about diet involves interpretation, assessment of understanding, and individualized instruction, which are nursing responsibilities. APs cannot provide education about new prescriptions or therapeutic diets.
C. Measuring urine output every 2 hr for a client recently diagnosed with a urinary tract infection: Measuring and recording urine output is a routine, stable, and predictable task that does not require professional judgment. APs are qualified to perform this task under supervision, making it appropriate for delegation.
D. Inserting a temporary nasogastric tube for a client who has a prescription for laboratory analysis of stomach contents: Nasogastric tube insertion is an invasive procedure requiring skill, assessment, and clinical judgment. It falls within the registered nurse’s scope of practice and cannot be delegated to an AP.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. "I will sleep on a soft mattress.": A soft mattress does not provide adequate joint support and may allow excessive joint flexion, increasing stiffness and discomfort in osteoarthritis. Firm or supportive surfaces help maintain proper spinal alignment and reduce mechanical stress on weight-bearing joints.
B. "I will apply a heating pad to make my hands feel better.": Heat therapy promotes vasodilation, increases blood flow, and relaxes periarticular muscles, which can reduce stiffness and improve joint mobility in osteoarthritis. Application of warm compresses or heating pads is particularly beneficial before activity to decrease morning stiffness and enhance range of motion.
C. "I will take aspirin on an empty stomach.": Aspirin and other nonsteroidal anti-inflammatory drugs (NSAIDs) can irritate the gastric mucosa by inhibiting prostaglandin synthesis, increasing the risk of gastritis and gastrointestinal bleeding. Taking these medications with food or milk reduces gastric irritation.
D. "I will exercise my joints as much as I can when they are inflamed.": During periods of acute inflammation, excessive joint use can worsen pain and tissue irritation. Low-impact, regular exercise is encouraged, but it should be balanced with rest during flare-ups to prevent additional joint stress and exacerbation of symptoms.
Correct Answer is A
Explanation
A. Call EMS if a seizure lasts 5 min or more: Prolonged seizures lasting 5 minutes or longer can progress to status epilepticus, a medical emergency that requires immediate intervention to prevent hypoxia, brain injury, or other complications. Parents should be instructed to activate emergency services promptly if seizures exceed this duration or if multiple seizures occur without full recovery.
B. Restrain the child at the onset of the seizure: Physical restraint during a seizure can cause injury to both the child and caregiver. Safe seizure management includes protecting the child from nearby hazards while allowing the seizure to run its course, rather than attempting to forcibly stop movements.
C. Offer the child a bubble bath every evening: Bubble baths are not specifically related to seizure safety or management. While baths can be part of routine hygiene, parents should avoid leaving the child unattended in water due to the risk of drowning during a seizure episode.
D. Place the child in a prone position during the seizure: Placing a child in the prone position increases the risk of airway obstruction and aspiration. Standard seizure safety includes positioning the child on their side (lateral recumbent) to maintain airway patency and facilitate drainage of secretions.
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