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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
a. “The client is in radiology department for a chest x-ray” Rationale:
a. The client's location in the radiology department is pertinent information for the oncoming nurse as they have to account for the patient’s whereabouts.
b. While family involvement is important, the timing of the partner's visit is not essential information for the oncoming nurse unless there were significant developments during the visit. c. This is expected of nursing practice.
d. The client's occupation or social status is not relevant to the immediate care needs and should not typically be included in a change-of-shift report.
Correct Answer is D
Explanation
a. While a client with type 1 diabetes using an insulin pump may require interdisciplinary collaboration for optimal management, this scenario does not suggest an immediate need for an interdisciplinary conference.
b. A client receiving heparin with an aPTT of 34 seconds may require adjustment of the heparin dosage, but this situation does not necessitate an interdisciplinary conference.
c. A client with orthostatic hypotension receiving IV fluids may require close monitoring and collaboration among healthcare providers, but this situation does not suggest an immediate need for an interdisciplinary conference.
d. A client at risk for pressure ulcers with an albumin level of 4.2 g/dl may require an interdisciplinary conference to address nutrition, wound care, and preventive measures to reduce the risk of pressure ulcer development.
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