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.

Answer and Explanation

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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Correct Answer is C

Explanation

A. Goggles are not typically necessary for droplet precautions unless there is a risk of splashing or spraying of respiratory secretions.
B. A gown is not specifically required for droplet precautions. However, if there is a risk of contamination from respiratory secretions, a gown may be used in addition to other precautions.
C. When setting up a meal tray for a client requiring droplet precautions, the nurse should wear a mask to protect against potential exposure to respiratory droplets.
D. Gloves are not typically required for setting up a meal tray under droplet precautions, as there is no direct contact with potentially contaminated surfaces.

A. Hold the container of solution 30 cm (12 in) above the anus. B. Hold the container of solution 15 cm (6 in) above the anus, then lower it 15 cm below the anus. C. Hold the container of solution level with the client's upper hip. D. Keep the container of solution at a level to maintain client comfort.

Correct Answer is A

Explanation

A. This is the appropriate height to allow the fluid flow by gravity.
B. This is such a short distance and the fluid wouldn't flow as desired.
C. Holding the container at the client's upper hip would not provide the appropriate angle for administering the enema.
D. This choice does not provide specific guidance on the height or angle for administering the enema, which is crucial for the procedure's effectiveness.

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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.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who requires droplet precautions. Which of the following personal protective equipment should the nurse wear when setting up the client's meal tray?

Correct Answer is C

Explanation

A nurse is preparing to administer a cleansing enema to a client. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

A nurse is having difficulty caring for a client due to variables affecting the communication process. Which of the following should the nurse identify as an interpersonal variable? (Select all that apply.)

A nurse is reviewing the laboratory results of a client who has a pressure ulcer. The nurse should identify an elevation in which of the following laboratory values as an indication that the client has developed an infection?

A nurse is providing discharge teaching for a client who requires home oxygen therapy. Which of the following statements should the nurse identify as an indication that the client needs further teaching?

A nurse is preparing a client's evening dose of risperidone when the tablet falls on the countertop. Which of the following actions should the nurse take?

A nurse is documenting information in a computerized health record. Which of the following nursing actions jeopardizes client confidentiality?

A nurse is assessing a client's bowel sounds. At which of the following points in the assessment should the nurse auscultate the client's abdomen?

A nurse is planning care for a client who has a decreased level of consciousness. The client is receiving continuous enteral feedings via a gastrostomy tube due to an inability to swallow. Which of the following is the priority action by the nurse?