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
The nurse should measure the gastric residual before administering a feeding to identify delayed gastric emptying. Gastric residual refers to the volume of formula or contents remaining in the stomach from the previous feeding. Measuring gastric residual helps assess how well the client's stomach is emptying and can indicate if there is delayed gastric emptying.
By measuring gastric residual, the nurse can:
● Determine if the stomach has adequately emptied from the previous feeding. ● Assess the client's tolerance to enteral feedings.
● Detect signs of delayed gastric emptying, which can be indicative of gastrointestinal motility issues or other complications.
● Adjust the feeding rate or make other modifications to the enteral feeding plan based on the amount of residual volume.
Confirming the placement of the NG tube is typically done using other methods, such as an X-ray, pH testing, or auscultation of air insufflation. Gastric residual measurement primarily serves the purpose of assessing gastric emptying, rather than confirming tube placement.
While electrolyte imbalances can be monitored in the overall care of a client receiving enteral feedings, measuring gastric residual specifically focuses on assessing gastric emptying and feeding tolerance, rather than determining the client's electrolyte balance.
Removing gastric acid that might cause dyspepsia is not the primary purpose of measuring gastric residual. Gastric residual measurement aims to evaluate the volume of the previous feeding and assess gastric emptying, rather than focusing on dyspepsia specifically.
Correct Answer is C
Explanation
A.Docusate sodium should not be taken with mineral oil, as the combination can increase the risk of adverse effects and reduce the effectiveness of the medication.
B.Docusate sodium is primarily used to prevent constipation by softening stools, not for treating diarrhea.
C.Docusate sodium is a stool softener that typically works within 1 to 3 days to produce softer stools, making this statement a correct understanding of its effects and timeline.
D.While it’s important to stay hydrated when taking docusate sodium, the statement is somewhat misleading. It is typically recommended to take docusate sodium with a full glass of water to help facilitate the softening of stools.
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