A nurse is assigning tasks to an assistive personnel (AP). Which of the following tasks should the nurse assign to the AP?

Change a dressing on an implanted central venous access device.

Suction a new tracheostomy.

Perform postmortem care.

Remove an NG tube.

Answer and Explanation

The Correct Answer is C

Rationale:

A. Change a dressing on an implanted central venous access device: This is a sterile procedure that requires assessment skills and knowledge of infection control. It must be performed by a licensed nurse, not an assistive personnel (AP).

B. Suction a new tracheostomy: Suctioning a new tracheostomy is a high-risk procedure requiring specialized knowledge to prevent hypoxia or trauma. Only a licensed nurse should perform this intervention.

C. Perform postmortem care: Postmortem care is within the scope of practice for an AP. It involves cleansing, positioning, and preparing the body for the family or mortuary, and does not require advanced clinical judgment or sterile technique.

D. Remove an NG tube: Removal of a nasogastric tube requires assessment and understanding of client tolerance and potential complications, which are responsibilities of a licensed nurse. It is not appropriate to delegate this task to an AP.

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Correct Answer is C

Explanation

Rationale:

A. Maintain sensory stimulation for the client: While in restraints, minimizing overstimulation is important to reduce agitation and prevent further aggressive behavior. Excessive sensory input can increase stress and escalate the situation rather than support safety.

B. Identify stressors that caused the client's aggression: Understanding triggers is important for long-term behavior management, but it is not the priority while the client is physically restrained. Immediate safety and monitoring take precedence over retrospective analysis.

C. Observe the client's range of movement: Continuous monitoring of the client’s range of motion is essential while restraints are in place to prevent injury, nerve damage, or impaired circulation. Regular checks ensure the restraints are applied safely and that the client maintains mobility as much as possible within safety limits.

D. Hold a critical incident debriefing about the client: Debriefing is important for staff learning and emotional processing after the event, but it occurs after the client is safe and restraints are removed. It is not an action to be performed while the client is restrained.

A. "Plan to take this medication with food." B. "Limit foods that contain folic acid while taking this medication." C. "Limit foods that contain vitamin D while taking this medication." D. "Plan to take this medication with antacids."

Correct Answer is A

Explanation

Rationale:

A. "Plan to take this medication with food.": Taking phenytoin with food can help reduce gastrointestinal irritation, such as nausea and upset stomach, which is a common side effect. Consistent administration with meals improves tolerability while maintaining therapeutic drug levels.

B. "Limit foods that contain folic acid while taking this medication.": Phenytoin can actually decrease folic acid absorption, and limiting folic acid intake could worsen potential deficiencies. Instead, monitoring and possibly supplementing folic acid may be recommended. Advising restriction could be harmful.

C. "Limit foods that contain vitamin D while taking this medication.": Phenytoin can reduce vitamin D metabolism, which may increase the risk of bone loss and fractures. Limiting vitamin D intake is not advised; rather, ensuring adequate vitamin D and calcium intake is important for older adults to maintain bone health.

D. "Plan to take this medication with antacids.": Antacids can interfere with the absorption of phenytoin, reducing its effectiveness. Taking phenytoin with antacids is contraindicated, and spacing the timing between antacids and phenytoin is necessary to maintain therapeutic levels.

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A nurse is assigning tasks to an assistive personnel (AP). Which of the following tasks should the nurse assign to the AP?

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Naxlex Comprehensive Predictor Exams

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