A nurse is assisting in the care of a group of clients on a medical-surgical unit. Which of the following tasks should the nurse delegate to an assistive personnel?

Removing packed gauze from a client's surgical dressing

Reinforcing the use of an incentive spirometer to a client

Determining the need for thickening agents while feeding a client

Repositioning a client who has a pressure injury

Answer and Explanation

The Correct Answer is D

A. Removing packed gauze from a client's surgical dressing: This is a sterile procedure that requires assessment of the wound, monitoring for infection, and clinical judgment. Only licensed nurses should perform this task to ensure safety and proper wound management.

B. Reinforcing the use of an incentive spirometer to a client: Teaching or reinforcing the use of medical devices requires understanding of technique, respiratory assessment, and the ability to correct improper use. This responsibility is within the licensed nurse’s scope of practice.

C. Determining the need for thickening agents while feeding a client: Assessing swallowing ability and determining the need for dietary modifications involves clinical judgment and knowledge of dysphagia management. Only a nurse or speech-language pathologist should perform this assessment.

D. Repositioning a client who has a pressure injury: Repositioning to prevent further pressure injury is within the scope of an assistive personnel. It involves following the nurse’s plan of care, using proper body mechanics, and implementing delegated interventions without requiring independent clinical judgment.

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Correct Answer is ["B","E"]

Explanation

A. Compulsive behaviors: The adolescent continues to pace, fold and unfold blankets, and engage in rigid organizing behaviors, indicating that compulsive behaviors are still present and have not yet improved.

B. BMI: The adolescent’s BMI increased from 16.1 (4th percentile) to 16.8 (9th percentile), reflecting weight gain and improvement in nutritional status, which is a positive clinical outcome in the treatment of anorexia nervosa.

C. Sleep: The adolescent slept little overnight and was awake frequently, showing that sleep disturbances persist. No improvement in sleep patterns is evident at this time.

D. Temperature: The adolescent’s temperature remains low at 35.8° C (96.4° F) two weeks ago and no updated reading shows normalization, indicating hypothermia has not resolved.

E. Heart rate: The heart rate improved from 48/min two weeks ago to 60–70/min today (assuming 41.7 kg weight), reflecting improved cardiovascular stability and physiologic recovery from malnutrition.

A. "Colostrum provides vitamin K, which is an essential nutrient for newborns." B. "Colostrum provides many important antibodies that the newborn lacks." C. "Colostrum contains a natural diuretic that stimulates the newborn to void." D. "Colostrum contains iron, which is important for a newborn's brain development."

Correct Answer is B

Explanation

A. "Colostrum provides vitamin K, which is an essential nutrient for newborns.": Vitamin K is administered separately via injection at birth to prevent hemorrhagic disease. Colostrum contains minimal vitamin K and is not the primary source for newborns.

B. "Colostrum provides many important antibodies that the newborn lacks.": Colostrum is rich in immunoglobulins, particularly IgA, which provides passive immunity and protects the newborn’s gastrointestinal tract from infections. These antibodies are crucial during the first days of life before the infant’s immune system is fully developed.

C. "Colostrum contains a natural diuretic that stimulates the newborn to void.": While colostrum has a mild laxative effect, its primary purpose is nutrient provision and immune protection rather than acting as a diuretic.

D. "Colostrum contains iron, which is important for a newborn's brain development.": Colostrum contains very low amounts of iron. Newborns rely on iron stores accumulated in utero, and breast milk alone does not provide sufficient iron for brain development in the first months.

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A nurse is assisting in the care of a group of clients on a medical-surgical unit. Which of the following tasks should the nurse delegate to an assistive personnel?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is ["B","E"]

Explanation

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Correct Answer is B

Explanation

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