A nurse has assigned an assistive personnel (AP) to perform a gastrostomy feeding for a client who has been receiving feedings at home. Which of the following actions should the nurse take to monitor the AP's performance of the task?
Tell the AP to list the steps of the task.
Instruct the AP to report back once the task is complete.
Ask the family if the AP performed the task correctly.
Request the AP to provide a return demonstration of the task.
The Correct Answer is D
A. Telling the AP to list the steps of the task is not sufficient to ensure correct performance. It may show knowledge of the steps, but it does not ensure the AP is performing the task correctly or safely.
B. Instructing the AP to report back once the task is complete does not allow the nurse to actively observe the AP’s technique or provide feedback on performance.
C. Asking the family if the AP performed the task correctly may provide subjective input, but the nurse is responsible for assessing and ensuring the proper completion of nursing tasks.
D. Requesting the AP to provide a return demonstration of the task is the best method. This allows the nurse to directly observe the AP’s technique, correct any errors, and ensure that the task is performed according to the prescribed standards. This also serves as a valuable teaching opportunity.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. "Take an extra dose of insulin lispro prior to aerobic exercise." This is incorrect. Exercise can increase insulin sensitivity, meaning the client may need to reduce the dose of short-acting insulin (such as insulin lispro) before exercise to avoid hypoglycemia. The nurse should not recommend taking an "extra" dose of insulin prior to exercise.
B. "Draw up the insulin lispro and insulin glargine in separate syringes." This is correct. Insulin lispro (a rapid-acting insulin) and insulin glargine (a long-acting insulin) should never be mixed in the same syringe. Insulin glargine is acidic, and mixing it with other insulins can alter its action and effectiveness.
C. "Expect insulin glargine to be cloudy." This is incorrect. Insulin glargine should be clear and colorless. If insulin glargine appears cloudy, it may indicate that the insulin is expired or has been improperly stored.
D. "Anticipate that the insulin glargine will peak in 3 hours." This is incorrect. Insulin glargine has no pronounced peak. It provides a steady release of insulin over 24 hours and is designed to be taken once daily.
Correct Answer is C
Explanation
A. Inspect the preschooler's tonsils for edema.: While tonsil inspection might be part of a general assessment, in a child with suspected epiglottitis, inspecting the throat should be avoided as it can trigger airway obstruction or cause further distress.
B. Collect a sputum sample.: Sputum collection is not typically indicated for epiglottitis diagnosis. A rapid diagnosis is essential to ensure timely intervention, and sputum samples are not a key diagnostic tool for this condition.
C. Determine the preschooler's oxygen saturation level.: Epiglottitis can lead to significant airway obstruction, so monitoring the oxygen saturation level is critical to assess for hypoxia and ensure adequate oxygenation. Early intervention may be required to maintain the child's airway.
D. Obtain a specimen for throat culture.: A throat culture should not be obtained in suspected epiglottitis, as manipulating the throat could cause complete airway obstruction. Immediate intervention to secure the airway is the priority.
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