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 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.

A. Use sterile water to inflate the balloon. B. Instruct the client to clean from front to back with an antiseptic solution. C. Collect urine from the catheter's port. D. Use a sterile specimen container.

Correct Answer is D

Explanation

When collecting a urine specimen via straight catheterization, it is important to use a sterile specimen container to maintain the integrity of the sample and prevent contamination. Using a non-sterile container can introduce bacteria and affect the accuracy of the culture and sensitivity results.

The other options mentioned are incorrect:

Using sterile water to inflate the balloon: This action is relevant when inflating the balloon of an indwelling urinary catheter, but in a straight catheterization, there is no balloon involved.

Instructing the client to clean from front to back with an antiseptic solution: This instruction is appropriate for cleaning the urethral meatus before inserting an indwelling urinary catheter, but in a straight catheterization, the nurse performs the procedure using sterile technique and does not require the client to clean themselves.

Collecting urine from the catheter's port: In a straight catheterization, the nurse collects urine directly from the catheter tube using a sterile syringe or collection container, rather than from a separate port.

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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

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Correct Answer is D

Explanation

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