A charge nurse is planning care for a group of clients on a medical-surgical unit. Which of the following tasks should the nurse delegate to an assistive personnel (AP)?

Giving a glycerin suppository to a client for constipation

Evaluating the effectiveness of ibuprofen administered to a client who reported a headache

Discussing dietary changes with a client who has a prescription for a gluten-free diet

Measuring hourly urinary output for a client who is postoperative

Answer and Explanation

The Correct Answer is D

A. Giving a glycerin suppository to a client for constipation: Medication administration, including rectal suppositories, requires assessment of bowel function, knowledge of contraindications, and evaluation of effectiveness, which fall under the responsibilities of a licensed nurse.

B. Evaluating the effectiveness of ibuprofen administered to a client who reported a headache: Assessing a client’s response to medication requires critical thinking, monitoring for adverse effects, and determining if additional interventions are needed, which are nursing responsibilities that cannot be assigned to assistive personnel.

C. Discussing dietary changes with a client who has a prescription for a gluten-free diet: Providing dietary education involves assessing the client’s current knowledge, identifying nutritional risks, and ensuring understanding of food choices, which requires professional nursing judgment or a consultation with a dietitian.

D. Measuring hourly urinary output for a client who is postoperative: Recording urinary output involves a simple measurement process that does not require clinical decision-making. Assistive personnel can accurately collect and document this data, allowing nurses to focus on interpretation and intervention if necessary.

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Correct Answer is B

Explanation

A. Notify the provider: While it is essential to inform the provider about the medication error, the immediate priority is to assess the client's condition first to determine if any adverse effects have occurred. The provider can be notified after ensuring the client is stable.

B. Check the condition of the client: The first action the nurse should take is to assess the client's condition. This includes monitoring for any immediate adverse effects or reactions related to the wrong medication administered. Ensuring the client's safety is the top priority in this situation.

C. Report the occurrence to the unit manager: Reporting the error to the unit manager is an important step in the process but should be done after assessing the client's condition. The immediate focus must be on the client's well-being before addressing administrative aspects of the error.

D. Complete an incident report: Completing an incident report is necessary for documenting the error and ensuring quality improvement measures, but it is not the first action. The nurse must first prioritize the assessment and safety of the client.

A. "The client has a new prescription for incentive spirometry." B. "The client's partner plans to return later today." C. "The client has no living family members." D. "I initiated a consultation by a nutritionist."

Correct Answer is ["A","B","C"]

Explanation

A. Speech-language pathologist: A speech-language pathologist specializes in assessing and treating swallowing disorders (dysphagia). They conduct swallowing evaluations and recommend appropriate strategies, exercises, and diet modifications to ensure safe swallowing and reduce the risk of aspiration.

B. Occupational therapist: An occupational therapist helps clients regain the ability to perform daily activities, including self-feeding. They provide adaptive strategies, recommend assistive devices, and work on improving fine motor skills to enhance independence during meals.

C. Dietitian: A dietitian assesses the client’s nutritional needs and recommends appropriate diet modifications, such as texture-altered foods or thickened liquids, to ensure adequate nutrition while reducing the risk of choking or aspiration. They collaborate with other team members to create a safe and balanced meal plan.

D. Psychologist: While a psychologist can help address emotional and psychological challenges following a stroke, they are not directly involved in managing swallowing difficulties. Their role focuses more on mental health, coping strategies, and emotional adjustment rather than dysphagia management.

E. Pharmacy technician: A pharmacy technician primarily assists with medication dispensing and does not have a role in evaluating or managing swallowing difficulties. Medication concerns related to swallowing would be addressed by a pharmacist rather than a pharmacy technician.

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A charge nurse is planning care for a group of clients on a medical-surgical unit. Which of the following tasks should the nurse delegate to an assistive personnel (AP)?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client and realizes they have administered the wrong medication. Which of the following actions should the nurse take first?

Correct Answer is B

Explanation

A newly licensed nurse is giving a change-of-shift report using Introductions, Situation, Background, Assessment, Recommendation (ISBAR) to an oncoming nurse. Which of the following statements by the newly licensed nurse should be included in the "Background" portion of the report?

Correct Answer is ["A","B","C"]

Explanation

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