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 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.
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