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.

Answer and Explanation

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.

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Correct Answer is A

Explanation

Elevating the head of the bed to a semi-Fowler's or high Fowler's position helps prevent aspiration during the feeding. This position facilitates proper digestion and reduces the risk of

regurgitation or reflux. It allows gravity to assist in keeping the feeding in the stomach and reduces the likelihood of complications.

The other actions mentioned are also important steps in the process but should be performed after elevating the head of the bed:

Measure stomach contents: This step is usually done before administering any enteral feeding to check for the presence of residual gastric contents. It helps determine if the client is tolerating previous feedings and guides adjustments in the feeding volume or rate if needed.

Return gastric content into the gastrostomy tube: If there is a significant amount of gastric residual, it is recommended to return the contents into the stomach before administering the feeding. This helps ensure that the client receives the full prescribed amount of the enteral feeding.

Flush the tube with water: Flushing the gastrostomy tube with water before and after the feeding helps maintain tube patency, clears any residual feeding or medication, and prevents clogging.

A. Acyclovir 400 mg PO twice daily B. Furosemide 80 mg PO daily C. Cimetidine 300 mg PO four times per day D. Meloxicam 5 mg PO once daily

Correct Answer is B

Explanation

Furosemide is a loop diuretic commonly prescribed for conditions such as hypertension and edema. One of the side effects of furosemide is the increased excretion of potassium in the urine, which can lead to low potassium levels in the body, known as hypokalemia. The other medications mentioned do not typically place the client at risk for hypokalemia: Acyclovir 400 mg PO twice daily: Acyclovir is an antiviral medication used to treat viral infections, such as herpes. It does not have a direct effect on potassium levels. Cimetidine 300 mg PO four times per day: Cimetidine is a histamine H2 receptor antagonist commonly used to reduce stomach acid production. It does not have a direct effect on potassium levels.

Meloxicam 5 mg PO once daily: Meloxicam is a nonsteroidal anti-inflammatory drug (NSAID) used for pain relief. It does not have a direct effect on potassium levels.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to administer a bolus enteral feeding to a client who has a gastrostomy tube. Which of the following actions should the nurse take first?

Correct Answer is A

Explanation

A nurse is reviewing the medication history of a client. The nurse should identify that which of the following medications places the client at risk for hypokalemia?

Correct Answer is B

Explanation

A nurse is preparing a sterile field for the insertion of a urinary catheter. Identify the sequence of actions the nurse should follow. (Move the steps into the box on the right, placing them in the selected order of performance. Use all the steps.)

A nurse is administering a tap-water enema to a client. The client reports cramping as the nurse instills the irrigating solution. Which of the following actions should the nurse take to relieve the client's discomfort?

A nurse is caring for a client who receives intermittent enteral feedings through an NG tube. Before administering a feeding, the nurse should measure the gastric residual for which of the following purposes?

A nurse is preparing to administer dextrose 5% in 0.45% sodium chloride 1000 mL to infuse at 100 mL/60 min. The drop factor on the manual IV tubing is 60 gtt/mL. The nurse should set the IV flow rate to deliver how many gtt/min? (Round to the nearest whole number.)

A nurse is preparing to administer 0.9% sodium chloride (NS) 100 mL IV to infuse over 4 hr. The drip factor of the manual IV tubing is 60 gtt/mL. The nurse should set the manual IV infusion to deliver how many gtt/min? (Round the answer to the nearest whole number.)

A nurse is reviewing the medical record of a client who has a peptic ulcer. Which of the following findings should the nurse identify as a risk factor for this condition?