A nurse in a long-term care facility is delegating care for a group of clients for the oncoming shift. Which of the following tasks should the nurse delegate to an assistive personnel? (Select all that apply.)

Plan care for a client who has dysphagia.

Transfer a client who is receiving radiation therapy to radiology.

Record urine output for a client who has a suprapubic catheter

Measure vital signs for a client who requires contact precautions.

Answer and Explanation

Correct Answer : B,C,D

A. Planning care, especially for a client with dysphagia (difficulty swallowing), involves assessment, evaluation, and critical thinking, which are within the scope of practice for licensed nurses, not APs. This task should not be delegated to an AP.

B. Transferring a client, especially one undergoing radiation therapy, often involves understanding specific precautions and handling techniques. This task is generally within the scope of APs, provided they have proper training and understand any specific precautions related to the client's condition.

C. Recording urine output is ataskthat can be delegated to an assistive personnel under the supervision of a registerednurse, as they do not require nursing judgment or assessment skills.

D. Measuring vital signs is a taskthat can be delegated to an assistive personnel under the supervision of a registered nurse, as they do not require nursing judgment or assessment skills.

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Correct Answer is A

Explanation

The correct answer is choice A. Instruct the client to lie supine with his knees flexed. Choice A rationale: This position reduces tension on the abdominal incision and can help minimize further protrusion of the abdominal contents. It also facilitates easier coverage of the wound and can help prevent additional injury. Choice B rationale: Semi-Fowler's position is not appropriate in this scenario because it can increase intra-abdominal pressure and exacerbate the evisceration. It may also make it more difficult to manage the protruding organs and to cover the wound adequately. Choice C rationale: Covering the wound with a dry sterile dressing is not sufficient in the case of evisceration. The exposed organs need to be kept moist to prevent tissue drying and damage. Sterile saline-soaked dressings are typically recommended in such cases. Choice D rationale: A transparent dressing is not appropriate for evisceration as it does not provide the necessary moisture and protection. Transparent dressings are more suitable for minor wounds or as secondary dressings but not for exposed internal organs.

A. "I might have short-term memory loss after the procedure." B. 17 will need to follow a full-liquid diet for 24 hours after the procedure." C. "I will have a urinary catheter in place during the procedure." D. I might have occasional seizures for several days after the procedure."

Correct Answer is A

Explanation

The correct answer is A. Electroconvulsive therapy (ECT) is a procedure that uses a mild electrical current to cause a brief seizure in the brain, which can help treat severe mentalhealth conditions. One of the possible side effects of ECT is short-term memory loss, which usually resolves within a few weeks. Therefore, if the client states that they might have short-term memory loss after the procedure, they indicate an understanding of the procedure and its risks. The other statements are incorrect or irrelevant. ECT does not require a full-liquid diet, a urinary catheter, or cause seizures after the procedure.

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A nurse in a long-term care facility is delegating care for a group of clients for the oncoming shift. Which of the following tasks should the nurse delegate to an assistive personnel? (Select all that apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has an abdominal surgical incision and notes an evisceration. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

A nurse in an inpatient mental health facility is reinforcing teaching with a client who signed a consent form for electroconvulsive therapy. Which of the following statements by the clientindicates an understanding of the procedure?

Correct Answer is A

Explanation

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