A charge nurse planning care for a group of clients is delegating tasks to an assistive personnel (AP). Which of the following tasks should the nurse delegate to the AP?
Administer an enteral feeding to a client who has a new gastrostomy tube.
Measure the output from a client's indwelling urinary catheter.
Evaluate a client's pain level 30 min after receiving an oral analgesic.
Reinforce foot care to a client who has a new diagnosis of diabetes mellitus.
The Correct Answer is B
Measuring the output from an indwelling urinary catheter is within the scope of practice for an assistive personnel (AP). It involves a straightforward task that does not require specialized nursing knowledge or judgment.
The other tasks mentioned should not be delegated to an AP:
Administer an enteral feeding to a client who has a new gastrostomy tube: Administering enteral feedings requires specialized knowledge and training to ensure proper placement and administration. This task should be performed by a licensed nurse.
Evaluate a client's pain level 30 min after receiving an oral analgesic: Evaluating pain level and the effectiveness of pain management requires nursing assessment and judgment. This task should be performed by a licensed nurse.
Reinforce foot care to a client who has a new diagnosis of diabetes mellitus: Providing education and reinforcing foot care to a client with a new diagnosis of diabetes requires
specialized knowledge about the disease and its management. This task should be performed by a licensed nurse.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Bisacodyl is a stimulant laxative commonly used to treat constipation. However, it is important to educate the client about the potential risks associated with chronic laxative use. The statement regarding electrolyte imbalance is important because excessive or prolonged use of laxatives can lead to electrolyte disturbances, such as low potassium levels (hypokalemia), which can have adverse effects on various body functions.
"Daily bowel movements are necessary for good intestinal health": While regular bowel movements are generally desirable, stating that daily bowel movements are necessary for good intestinal health is an overgeneralization. Bowel movement frequency can vary among individuals, and it is important to consider other factors such as diet, hydration, and overall health.
"Chronic use of laxatives can lead to a tear in the rectal mucosa": While chronic use of laxatives can lead to complications such as dependence and potential damage to the digestive system, specifically mentioning a tear in the rectal mucosa (rectal mucosal injury) is not the most commonly associated concern.
"Decrease your intake of high-fiber foods": It is generally recommended to increase fiber intake for individuals with constipation. Decreasing high-fiber foods would counteract the benefits of dietary fiber in promoting regular bowel movements and alleviating constipation.
Correct Answer is B,A,C,D
Explanation
The correct sequence of steps the nurse should take to administer the enema is:
1. Provide for the client's privacy by closing the curtains.
2. Confirm the client's identity by checking her wristband.
3. Assist the client into the Sims position.
4. Insert the tip of the enema tubing into the client's rectum.
Proper infection control measures, preparing the enema solution, monitoring the flow rate, and documenting the procedure are among other important considerations that should be taken into account.
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