A nurse and an assistive personnel (AP) are caring for a client who requests a PRN pain medication. After the nurse administers the medication, which of the following tasks should the nurse assign to the AP?

Document the client's respiratory rate in 1 hr.

Monitor the client for an allergic reaction for 30 min.

Check the client's response to the medication in 1 hr.

Evaluate the client for therapeutic effects in 30 min.

Answer and Explanation

The Correct Answer is A

A.   Documenting the client's respiratory rate in 1 hour is within the scope of practice for an assistive personnel (AP) and does not require nursing judgment or assessment.
B.   Monitoring the client for an allergic reaction for 30 minutes requires nursing judgment and assessment skills to recognize signs and symptoms of allergic reactions.
C.   Checking the client's response to the medication in 1 hour requires nursing judgment and assessment skills to evaluate pain relief and any adverse effects.
D.   Evaluating the client for therapeutic effects in 30 minutes requires nursing judgment and assessment skills to determine the effectiveness of the pain medication.

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Correct Answer is B

Explanation

A) Allowing the infant to have soft foods is not recommended immediately following surgery to protect the surgical site.

B) Maintaining elbow restraints prevents the infant from touching or injuring the repair site, which is crucial for proper healing.

C) Feeding the infant with a spoon could disrupt the surgical site and is not advised until cleared by a healthcare provider.

D) While oral hygiene is important, brushing the infant's teeth could harm the repair site; however, specific post-operative care instructions regarding oral hygiene should be provided by the healthcare provider, which may or may not include a temporary cessation of brushing.

A. Encourage the client to talk about current events. B. Give directions using simple phrases. C. Orient the client to time and place twice per day. D. Rotate assistive personnel to help the client with ADLs.

Correct Answer is B

Explanation

A. Encouraging the client to talk about current events may not be effective, as individuals with Alzheimer's disease may have difficulty following complex conversations or remembering recent events.
B. Giving directions using simple phrases is essential for effective communication with individuals who have Alzheimer's disease. Using clear, concise language helps reduce confusion and frustration and improves the client's ability to understand and follow instructions.
C. Orienting the client to time and place twice per day can be helpful for some individuals with Alzheimer's disease, but the frequency and method of orientation may vary depending on the client's specific needs and preferences. It may not be necessary to orient the client twice per day in all cases.
D. While it's important to provide consistent care to clients with Alzheimer's disease, rotating assistive personnel frequently may lead to confusion and distress for the client. Consistency and familiarity with caregivers can help establish trust and improve the client's sense of security.

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A nurse and an assistive personnel (AP) are caring for a client who requests a PRN pain medication. After the nurse administers the medication, which of the following tasks should the nurse assign to the AP?

Nursing Test Bank

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