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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Rationale:
A. "Controlled substances are kept in the bottom drawer of the medication cart.": Controlled substances are stored in locked, secure medication dispensing systems or locked drawers—not casually in the bottom drawer. Security measures are in place to prevent diversion and ensure accurate tracking.
B. "I should verify the number of controlled substances at the end of the shift. The provider is responsible for inventory of controlled substances.": While end-of-shift counts are standard practice, the nurse not the provider is responsible for verifying inventory at shift change. Accountability for handling and documenting controlled substances lies with nursing staff.
C. "If a controlled substance requires a waste, a second nurse must witness the waste.":
This is a correct and essential safety protocol. When wasting part of a controlled substance dose, a second licensed nurse must witness and document the waste to prevent diversion and ensure accurate medication tracking.
D. "Computer controlled substance inventory is reported to the Drug Enforcement Administration every 10 years.": Facilities are required to maintain records and conduct regular audits, and the DEA mandates inventory at least every 2 years not every 10. Reporting frequency and requirements are more stringent.
Correct Answer is B
Explanation
Rationale:
A. "My anxiety has been getting a little easier to deal with every day." Naltrexone is not primarily used to treat anxiety. While improvement in anxiety may occur secondarily as alcohol use decreases, this statement does not directly reflect the intended therapeutic effect of naltrexone in substance use treatment.
B. "I have not had any cravings to drink since my visit last week." Naltrexone works by blocking opioid receptors involved in the brain’s reward system, reducing cravings and the pleasurable effects of alcohol. Decreased alcohol craving is a direct and expected response to naltrexone therapy in clients with alcohol use disorder.
C. "When I had one drink last week. I had extreme nausea and vomited several times."
This describes the effect of disulfiram, not naltrexone. Disulfiram causes an aversive reaction to alcohol, while naltrexone does not produce sickness when alcohol is consumed; it simply reduces the reward response.
D. “Since I quit drinking. I have not had any hallucinations." Hallucinations are associated with alcohol withdrawal, not the effect of naltrexone. Naltrexone does not prevent withdrawal symptoms or hallucinations; it is used after detox to help maintain abstinence and reduce relapse.
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