A charge nurse is making client care assignments. Which of the following tasks should the nurse delegate to assistive personnel (AP)? (Select all that apply.)
Assist a client to ambulate using a gait belt.
Review a low-sodium diet for a client who has hypertension.
Feed a client who had a stroke 3 months ago.
Bathe a client who had an amputation 2 days ago.
Expllain oral hygiene to a client receiving chemotherapy.
Correct Answer : A,C,D
Rationale A: Assisting a client to ambulate using a gait belt is a task within the scope of practice for assistive personnel. It involves physical support and monitoring, which do not require the advanced training of a registered nurse. This task ensures the client's safety while promoting mobility.
Rationale B: Reviewing a low-sodium diet is not within the scope of practice for assistive personnel as it requires nutritional knowledge and the ability to teach, which are responsibilities of a registered nurse or a dietitian.
Rationale C: Feeding a client who had a stroke 3 months ago can be delegated to assistive personnel. This task does not require the clinical judgment of a nurse and can be performed following a predefined plan of care.
Rationale D: Bathing a client who had an amputation 2 days ago can be delegated to assistive personnel. They are trained to assist with activities of daily living, including bathing, while ensuring the client's safety and comfort.
Rationale E: Explaining oral hygiene to a client receiving chemotherapy involves patient education and understanding of the specific needs related to the client's condition, which are beyond the role of assistive personnel. This task requires the expertise of a nurse or other healthcare professional.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
a. Hypertension and crackles:
While hypertension can be associated with various conditions, such as cardiovascular diseases or stress, it is not directly related to the cessation of TPN infusion.
Crackles in the lungs are often indicative of fluid accumulation or inflammation, commonly seen in conditions like pneumonia or heart failure. They are not typically associated with the interruption of TPN infusion.
b. Fever and chills:
Fever and chills can be symptoms of infection or inflammatory processes in the body. However, they are not specifically related to the interruption of TPN infusion.
In the context of TPN cessation, the focus would be on metabolic changes rather than infectious processes.
c. Excessive thirst and urination:
Excessive thirst and urination are classic symptoms of hyperglycemia, which can occur when TPN, particularly if it contains a high glucose concentration, is abruptly interrupted.
When TPN infusion stops, there is no longer a continuous supply of glucose to the body, leading to increased blood glucose levels and subsequent polyuria (excessive urination) and polydipsia (excessive thirst) as the body tries to eliminate excess glucose.
d. Shakiness and diaphoresis:
Shakiness and diaphoresis (excessive sweating) are classic symptoms of hypoglycemia, which can occur if TPN, particularly if it contains a high concentration of insulin, is abruptly interrupted.
TPN solutions often contain glucose and insulin to maintain proper blood glucose levels. If the infusion is stopped suddenly, there may be a rapid decline in blood glucose levels, leading to hypoglycemia, which manifests as shakiness, diaphoresis, confusion, and other neuroglycopenic symptoms.
Correct Answer is D
Explanation
A) The dorsal surface of the foot is not the most reliable site to assess for cyanosis in individuals with dark skin because the skin pigmentation can mask the bluish tint that indicates reduced oxygenation.
B) Similarly, the dorsal surface of the hand may not clearly show cyanosis due to the thickness and pigmentation of the skin, which can obscure the color change.
C) The pinnae of the ears may also not be the best indicator of cyanosis in dark-skinned individuals because peripheral areas like the ears can be affected by environmental temperatures, leading to misleading color changes.
D) The conjunctivae, however, are a mucous membrane where the skin pigmentation does not affect visibility. Therefore, it is an appropriate site for assessing cyanosis as it allows for the observation of subtle changes in color that indicate hypoxia. This is why the conjunctivae are the correct site to examine for cyanosis in a client with dark skin.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.