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
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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
a. Green tags are used for the "walking wounded" who will need medical care at some point after more critical injuries have been treated. This would not be appropriate for a client with full thickness burns on 72% of his body, as this condition is life-threatening and requires immediate attention.
b. Yellow tags are for those who require observation and possible later re-triage. Their condition is stable for the moment, and they are not in immediate danger of death. This client's condition, however, is too critical for a yellow tag.
c. Black tags are typically used for individuals who are deceased or expected to die imminently. The chances of survival for this patient are very minimal since the burn surface area is more than 50% with full thickness burns
d. Red tags are for those with severe injuries who require immediate treatment but have a chance of survival.
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Correct Answer is B
Explanation
a. Advising the newly licensed nurse to complete less time-consuming tasks first may not address the underlying issue of difficulty focusing and prioritizing care effectively.
b. Recommending that the newly licensed nurse take time to plan at the beginning of his shift can help him organize tasks and prioritize care more effectively.
c. While offering to provide care for his clients while he takes a break is supportive, it does not address the underlying issue of difficulty focusing and prioritizing care.
d. Asking other staff members to take over some of his tasks may be necessary in some situations but should not be the first intervention. Helping the nurse develop strategies to improve focus and organization is more appropriate.
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