A nurse in a long-term care facility is making client care assignments for the unit. Which of the following tasks should the nurse assign to an assistive personnel?
Changing a sterile dressing on a client's open wound
Performing postmortem care for a client
Interpreting a client's laboratory values
Inserting a client's NG tube
The Correct Answer is B
Rationale:
A. Changing a sterile dressing on a client's open wound: Sterile procedures require nursing judgment and knowledge of aseptic technique. This task falls within the scope of practice for licensed nurses, not assistive personnel.
B. Performing postmortem care for a client: Postmortem care, such as cleaning the body and preparing it for transport, is a non-sterile, routine task that can be safely delegated to assistive personnel in accordance with facility policy and under nurse supervision.
C. Interpreting a client's laboratory values: Interpretation of lab results requires clinical judgment and is the responsibility of licensed personnel. Assistive personnel are not trained or authorized to interpret clinical data.
D. Inserting a client's NG tube: Inserting a nasogastric tube is an invasive procedure that requires assessment and verification of placement. This task is beyond the scope of assistive personnel and should be performed by a nurse.
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Related Questions
Correct Answer is D
Explanation
Rationale:
A. Seeking clarification: Seeking clarification involves asking the client to explain something they have already said to ensure mutual understanding. It usually occurs in response to ambiguous or unclear statements, not as an initial, open-ended invitation to speak.
B. Reflecting: Reflecting is a technique in which the nurse restates the client’s feelings or thoughts to encourage deeper exploration. The nurse in this case is not restating anything but is instead prompting the client to share independently.
C. Focusing: Focusing involves guiding the conversation toward a specific topic or detail the client has already brought up. Since the nurse is initiating a broad and open-ended question, focusing is not the technique being used here.
D. Giving broad openings: This technique encourages the client to take the lead in the conversation by expressing themselves freely. Asking this question invites open communication and helps build rapport, which is characteristic of broad opening statements.
Correct Answer is A
Explanation
Rationale:
A. Evaluate the client's coping skills: Secondary prevention focuses on early identification and prompt intervention to prevent worsening of a condition. Assessing the client’s coping skills helps the nurse identify maladaptive behaviors or psychological distress early, allowing for timely referral or intervention.
B. Explore the client's desired goals: Exploring future goals is tertiary prevention, which aims at restoring function and promoting long-term adaptation after a life event. While important, it does not address immediate detection or intervention needs during an acute phase.
C. Discuss available support systems with the client: This is a supportive and therapeutic action, but it is part of tertiary prevention, which promotes recovery and prevents further decline. It is not as immediate or diagnostic as evaluating current coping abilities.
D. Ensure the safety of the client: Ensuring client safety is always a priority if there is any indication of harm or suicidal ideation. However, if no imminent safety risk is present, it does not serve as the main focus of secondary prevention, which emphasizes early detection and screening.
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