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. Perform hand hygiene. B. Place the sterile package on the work surface. C. Open the outermost flap of the package away from the body. D. Open the side flaps of the package. E. Open the innermost flap of the package toward the body. F. Use the inner surface of the package as a sterile field.

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.

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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 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.)

Correct Answer is A,B,C,D,E,F

Explanation

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