A nurse from a medical-surgical unit is floating to a postpartum unit. Which of the following clients is an appropriate assignment for the nurse to accept?
A client who had a cesarean delivery 24 hr ago
A client who is receiving oxytocin for uterine atony
A client who will be breastfeeding for the first time
A client who underwent removal of a retained placenta
The Correct Answer is A
A. A client who had a cesarean delivery 24 hr ago: A medical-surgical nurse has the knowledge and skills to monitor a postoperative client, including assessment of vital signs, pain management, incision care, and early ambulation. This assignment is appropriate because it involves standard post-surgical care that aligns with the nurse’s current competencies.
B. A client who is receiving oxytocin for uterine atony: Oxytocin administration for active uterine atony requires rapid recognition of hemorrhage, titration of medication, and frequent maternal and fetal monitoring. A nurse unfamiliar with postpartum complications may not safely manage this high-risk situation, making it inappropriate for a float assignment.
C. A client who will be breastfeeding for the first time: Assisting a new mother with initial breastfeeding requires specialized knowledge of latch techniques, positioning, and management of common breastfeeding issues. A nurse without postpartum or lactation experience may not provide safe or effective guidance, making this assignment unsuitable.
D. A client who underwent removal of a retained placenta: This client is at high risk for postpartum hemorrhage and requires frequent assessment and immediate intervention if complications occur. Management of such a high-acuity postpartum client exceeds the typical scope of a medical-surgical nurse without specialized obstetric experience.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Subcutaneous: The subcutaneous route deposits medication into the fatty tissue beneath the skin. PPD testing requires a slow, localized immune reaction, which cannot be accurately assessed if administered subcutaneously, making this route inappropriate.
B. Intramuscular: Intramuscular injections deliver medication into muscle tissue for systemic absorption. PPD relies on a localized delayed-type hypersensitivity reaction in the dermis, so IM administration would prevent accurate interpretation of the test.
C. Intradermal: PPD is administered intradermally, usually on the inner forearm, to produce a small, raised wheal. This allows for proper exposure of immune cells in the dermis to the antigen, enabling assessment of induration 48–72 hours later and accurate detection of tuberculosis exposure.
D. Oral: Oral administration does not provide a localized skin reaction necessary for PPD testing. The immune response required for interpreting the test cannot occur via the gastrointestinal route, making oral administration inappropriate.
Correct Answer is C
Explanation
A. Evaluating the effectiveness of acetaminophen administered 30 min ago to a client who reported a headache: Assessing medication effectiveness requires professional judgment to evaluate pain relief, side effects, and changes in condition. This is within the registered nurse’s scope of practice and cannot be delegated to an assistive personnel (AP).
B. Discussing upcoming dietary changes with a client who has a new prescription for a low-cholesterol diet: Teaching about diet involves interpretation, assessment of understanding, and individualized instruction, which are nursing responsibilities. APs cannot provide education about new prescriptions or therapeutic diets.
C. Measuring urine output every 2 hr for a client recently diagnosed with a urinary tract infection: Measuring and recording urine output is a routine, stable, and predictable task that does not require professional judgment. APs are qualified to perform this task under supervision, making it appropriate for delegation.
D. Inserting a temporary nasogastric tube for a client who has a prescription for laboratory analysis of stomach contents: Nasogastric tube insertion is an invasive procedure requiring skill, assessment, and clinical judgment. It falls within the registered nurse’s scope of practice and cannot be delegated to an AP.
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