A charge nurse is making shift assignments on a medical-surgical unit. Which of the following tasks should the nurse assign to the AP?

Measuring oxygen saturation for a client who has dyspnea

Performing nasal hygiene for a client who has an NG tube

Pouching a client's ostomy bag for a new colostomy

Inserting a rectal suppository for a client who is vomiting

Answer and Explanation

The Correct Answer is C

a.   Measuring oxygen saturation requires nursing judgment and assessment skills, which are beyond the scope of practice for an assistive personnel (AP).
b.   Nasal hygiene for a client with an NG tube involves specific skills and requires nursing assessment to ensure proper technique and patient comfort.
c.   Pouching a client's ostomy bag involves routine care that can be safely performed by assistive personnel under the direction and supervision of a nurse.
d.   Inserting a rectal suppository requires nursing judgment and assessment to determine appropriateness based on the client's condition, which is beyond the scope of practice for an AP.

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Correct Answer is B

Explanation

a. Administering a sedative should not be the first response, as it may not address the underlying cause of the behavior and may increase the risk of adverse effects.
b. Contacting a family member to provide support and comfort to the client can help alleviate agitation and may help redirect the client's behavior.
c. Placing the client in a wheelchair with a lap tray does not address the underlying cause of the behavior and may not be effective in managing agitation.
d. Keeping the client in her room with the door closed may isolate the client but does not address the underlying cause of the behavior or provide appropriate support.

A. Continue the medication dosages that relieve the client’s pain B. Contact the provider about replacing the opioid with an NSAID C. Administer the benzodiazepine but withhold the opioid D. Withhold the benzodiazepine but continue the opioid

Correct Answer is D

Explanation

a. Continuing both medications may exacerbate the somnolence and difficulty arousing experienced by the client. It's essential to address the adverse effects promptly.
b. NSAIDs are not typically the first choice for severe pain management in terminal illness, especially when opioids are already prescribed. Moreover, replacing the opioid with an NSAID may not adequately address the pain.
c. Administering the benzodiazepine alongside the opioid may further potentiate the sedative effects and worsen the client's condition.
d. This is the most appropriate action. Withholding the benzodiazepine can help mitigate the sedation while continuing the opioid ensures ongoing pain relief for the client's comfort without introducing additional sedating medications.

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A charge nurse is making shift assignments on a medical-surgical unit. Which of the following tasks should the nurse assign to the AP?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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