A charge nurse is reviewing the list of tasks that have been delegated to the assistive personnel (AP) by the staff nurse. Which of the following tasks should the charge nurse reassign to a licensed nurse?

Removing and cleaning the cannula of a client who has a new tracheostomy

Providing a back rub to a client who has right-sided paralysis

Transporting a client who experienced a stroke 72 hr ago to the radiology department

Performing oral hygiene for a client who is 1 day postoperative following an amputation of the right arm

Answer and Explanation

The Correct Answer is A

A.   Removing and cleaning the cannula of a tracheostomy requires specialized training and should be performed by a licensed nurse or respiratory therapist.
B.   Providing a back rub is within the scope of practice for assistive personnel and does not require specialized training.
C.   Transporting a client to the radiology department does not require specialized nursing skills and can be safely performed by assistive personnel.
D.   Performing oral hygiene for a client postoperative following an amputation does not require specialized nursing skills and can be safely performed by assistive personnel.

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Correct Answer is D

Explanation

A. Positioning the client on the right side is not a standard practice for gastric lavage. Instead, the client is usually placed in a supine position or with the head of the bed elevated.
B. Instilling sterile saline may be part of the gastric lavage procedure, but the volume and type of solution used depend on the specific clinical situation and should be determined by the
healthcare provider's orders.

C. Connecting the NG tube to high continuous suction is not typically done during gastric lavage. Suction may be used intermittently, but continuous high suction can cause mucosal damage.
D. During gastric lavage, the nurse should continue to withdraw fluid until it is clear to remove gastric contents and toxins effectively. This ensures that the stomach is adequately irrigated.

A. "Examine your feet carefully every day." B. "Wear compression stockings daily." C. "Maintain stable blood glucose levels." D. "Have an eye examination once per year."

Correct Answer is C

Explanation

While foot care is important for preventing diabetic foot complications, including ulcers and amputations, it is not directly related to preventing retinopathy and nephropathy.

Compression stockings may be helpful for managing venous insufficiency and preventing deep vein thrombosis (DVT) but are not specifically indicated for preventing retinopathy and nephropathy in clients with diabetes mellitus.

Maintaining stable blood glucose levels is essential for preventing the long-term complications of diabetes mellitus, including retinopathy (damage to the blood vessels in the retina) and nephropathy (kidney damage).

Having regular eye examinations is important for early detection and management of diabetic retinopathy, but it is only one aspect of comprehensive diabetes care. Maintaining stable blood glucose levels is crucial for preventing retinopathy and nephropathy.

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A charge nurse is reviewing the list of tasks that have been delegated to the assistive personnel (AP) by the staff nurse. Which of the following tasks should the charge nurse reassign to a licensed nurse?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is performing gastric lavage on a client using a large-bore NG tube. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

A nurse is teaching an older adult client diagnosed with diabetes mellitus about preventing the long-term complications of retinopathy and nephropathy. Which of the following instructions should the nurse include?

Correct Answer is C

Explanation

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