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 A,B,C,D,E,F
Explanation
To prepare a sterile field for the insertion of a urinary catheter, the nurse should follow the sequence of actions in the following order:
1. Perform hand hygiene.
2. Place the sterile package on the work surface.
3. Open the outermost flap of the package away from the body.
4. Open the side flaps of the package.
5. Open the innermost flap of the package toward the body.
6. Use the inner surface of the package as a sterile field.
Following this sequence ensures that the nurse maintains proper hand hygiene, prepares the sterile package, and opens it in a way that maintains sterility. Opening the flaps in the correct order helps create a sterile field within the package, which can be used for the insertion of the urinary catheter.
Correct Answer is B
Explanation
When reinforcing teaching about cimetidine with a client who has peptic ulcer disease, the nurse should include the following information:
"Wait at least 1 hour after taking the medication before taking an antacid.": Cimetidine is a histamine-2 receptor antagonist that reduces stomach acid production. Taking an antacid too close in time to cimetidine may decrease its effectiveness as antacids can interfere with its absorption. The nurse should advise the client to follow the healthcare provider's instructions regarding the timing and administration of cimetidine and antacids.
The following statements are incorrect or not applicable:
"Expect breast tenderness while taking this medication.": Breast tenderness is not a common side effect of cimetidine. If the client experiences any unusual symptoms or side effects while taking the medication, they should consult their healthcare provider for further evaluation.
"Take this medication on an empty stomach.": To reduce stomach upset, this medication should be taken with food or milk
"Take ibuprofen for occasional aches and pains.": Ibuprofen is a nonsteroidal anti-inflammatory drug (NSAID) that can increase the risk of gastrointestinal complications, including ulcers. In individuals with peptic ulcer disease, it is generally recommended to avoid NSAIDs unless specifically prescribed by a healthcare provider. The nurse should emphasize the importance of discussing any pain management strategies or medications with the healthcare provider before use.
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