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.
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Related Questions
Correct Answer is ["A","B","C"]
Explanation
A. Measurement of residual urine after urination is an indication of urinary catheterization because it can help diagnose conditions such as neurogenic bladder, bladder outlet obstruction, or urinary retention.
B. An open perineal wound is an indication for urinary catheterization because it can prevent contamination of the wound by urine and facilitate wound healing.
C. Relief of urinary retention is an indication of urinary catheterization because it can prevent complications such as bladder distension, infection, or renal damage.
D. Convenience for the nursing staff or the client's family is not an indication of urinary catheterization because it can increase the risk of catheter-associated urinary tract infection (CAUTI), trauma, or encrustation.
E. routine acquisition of a urine specimen is not an indication for urinary catheterization because it can be obtained by other methods such as clean catch, midstream, or suprapubic aspiration.
Correct Answer is ["A","B","D","E"]
Explanation
A. More difficulty seeing due to a greater sensitivity to glare is a common age-related change in vision.
B. Dehydration of intervertebral discs can occur with aging, leading to decreased flexibility and potentially contributing to back pain.
C. While systolic blood pressure may increase with age, decreased systolic blood pressure is not a typical age-related change.
D. Decreased cough reflex is an expected change, which can lead to an increased risk of respiratory infections in older adults.
E. Decreased bladder capacity is an expected age-related change due to changes in the bladder muscles and elasticity of the tissues. This can contribute to increased frequency of urination in older adults.
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