A nurse is assigning client care tasks to an assistive personnel (AP) for the upcoming shift. Which of the following tasks is within the AP's scope of practice?
Interpret the client's need for pain medication.
Change a sterile dressing on a client's open incisional wound.
Educate a client on the use of a glucometer.
Perform cardiopulmonary resuscitation on a client.
The Correct Answer is D
A. Interpret the client's need for pain medication: Determining the need for analgesia requires professional nursing judgment and assessment, which is outside the AP’s scope of practice. The nurse must evaluate pain and make medication decisions.
B. Change a sterile dressing on a client's open incisional wound: Sterile dressing changes involve invasive procedures and assessment of wound healing, which are nursing responsibilities. APs can assist with non-sterile care but cannot perform sterile interventions independently.
C. Educate a client on the use of a glucometer: Patient education involves teaching, assessing understanding, and clinical judgment, all of which require nursing expertise. APs can reinforce teaching but cannot independently instruct clients on medical device use.
D. Perform cardiopulmonary resuscitation on a client: CPR is a basic life-saving procedure that APs are trained and authorized to perform in emergencies. This task falls within the AP’s scope of practice and can be done under general supervision until advanced help arrives.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Apply sterile gloves: Standard precautions are followed when handling feeding equipment, but sterile gloves are not required for routine administration of intermittent gastric feedings. Clean gloves are sufficient to prevent contamination.
B. Assess gastric residual volume: Checking gastric residual volume before feeding helps evaluate the client’s tolerance of the previous feeding and reduces the risk of aspiration. High residual volumes may indicate delayed gastric emptying and the need to hold or adjust the feeding.
C. Flush the tube with 60 mL of sodium chloride: Flushing the tube is important before and after feedings to maintain patency, but the amount and timing depend on institutional protocol. It is performed after assessing residual volume rather than as the first step.
D. Chill the formula: Feeding formulas should generally be at room temperature to prevent gastrointestinal discomfort and cramping. Chilling the formula is not recommended prior to administration.
Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A,B"},"C":{"answers":"B"},"D":{"answers":"B"}}
Explanation
Rationale
• Genitourinary findings: Intermittent sensations of "squeezing or spasm" in the bladder or urinary tract are typical in multiple sclerosis due to autonomic nervous system involvement and demyelination affecting bladder control. These symptoms are less common in ALS, which primarily affects motor neurons without early autonomic involvement.
• Report about gait: Episodes of leg weakness and balance issues can occur in both ALS and MS. ALS causes progressive motor weakness affecting gait due to upper and lower motor neuron degeneration. MS can cause intermittent gait disturbances from demyelination in the central nervous system, often with exacerbations and remissions.
• Vision disturbance: Intermittent double vision is consistent with MS, reflecting demyelination of cranial nerves or the optic pathways. Visual symptoms, including diplopia or optic neuritis, are hallmark early signs of MS. ALS typically does not involve vision, making this symptom specific to MS.
• Energy level: Fatigue lasting more than 4 months aligns with MS, which frequently causes persistent fatigue due to both neurological dysfunction and immune-mediated inflammation. ALS may lead to fatigue later in disease progression, but early chronic fatigue is more characteristic of MS.
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