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
Explanation
When reinforcing teaching with a client who has a new prescription for aluminum hydroxide to treat heartburn, the nurse should include constipation as an adverse effect of the medication. Aluminum hydroxide is an antacid commonly used to neutralize stomach acid and provide relief from heartburn and indigestion. However, one of its potential side effects is constipation. Aluminum hydroxide can slow down intestinal motility, leading to infrequent or difficult bowel movements.
Hypertension: Aluminum hydroxide is not known to cause hypertension (high blood pressure). However, clients with pre-existing hypertension should be cautious when using antacids containing sodium bicarbonate, as the sodium content may impact blood pressure levels.
Flatulence: Flatulence (excessive gas) is not a common adverse effect of aluminum hydroxide. It primarily works by neutralizing stomach acid and does not typically cause increased gas production.
Headache: Headache is not commonly reported as an adverse effect of aluminum hydroxide. It is more likely to be associated with other factors such as the underlying condition causing heartburn or individual factors.
Correct Answer is ["100"]
Explanation
To calculate the IV flow rate in drops per minute (gtt/min), you can use the following formula: Flow rate (gtt/min) = (Volume to be infused in mL) x (Drop factor) / (Time in minutes) In this case, the volume to be infused is 100 mL, the drop factor is 60 gtt/mL, and the time is 60 minutes.
Flow rate (gtt/min) = (100 mL) x (60 gtt/mL) / (60 min)
Canceling out the mL and min units, the formula becomes:
Flow rate (gtt/min) = 100 x 60 / 60
Flow rate (gtt/min) = 100
Therefore, the nurse should set the IV flow rate to deliver 100 gtt/min.
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