A nurse is assisting with planning care for a group of clients. Which of the following tasks should the nurse delegate to an assistive personnel?
Changing the dressing on a client's IV site
Suctioning a client's new tracheostomy
Evaluating a client's risk for developing pressure injuries
Administering a large-volume enema to a client
The Correct Answer is D
A. Changing the dressing on a client's IV site: This is a sterile procedure and requires the nurse’s clinical expertise. It cannot be delegated to assistive personnel (AP).
B. Suctioning a client's new tracheostomy: Suctioning a tracheostomy, especially a new one, is a sterile procedure requiring clinical judgment and skill, which is beyond the scope of assistive personnel.
C. Evaluating a client's risk for developing pressure injuries: This is an assessment task that requires clinical judgment and critical thinking. It falls under the nurse’s scope of practice and should not be delegated to AP.
D. Administering a large-volume enema to a client: Assisting with or administering an enema is a task that can be delegated to assistive personnel, as it is within their scope of practice, provided the client is stable and the procedure does not require complex judgment.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. A warm extremity is not typically associated with compartment syndrome. Compartment syndrome may present with coolness due to compromised circulation.
B. Moderate pain on the ankle may be present in compartment syndrome due to increased pressure within the compartment, but it is not a specific manifestation.
C. Blanch time of 2 seconds in the toenail beds indicates normal capillary refill, which is not consistent with compartment syndrome. In compartment syndrome, capillary refill may be delayed.
D. Palpation of a weak or absent dorsalis pedis pulse is a concerning finding indicative of compromised circulation, a hallmark sign of compartment syndrome.
Correct Answer is D
Explanation
A. Incorrect. While limiting sodium intake is important for overall health, it is not typically emphasized specifically during pregnancy unless there are specific medical indications.
B. Incorrect. While fiber is important for digestive health, the focus during pregnancy is usually on ensuring an adequate intake of nutrients like iron, calcium, and folate.
C. Incorrect. While staying hydrated is important during pregnancy, there is no specific recommendation for a set number of glasses of fluids per day. Fluid needs can vary depending on factors such as activity level, climate, and individual health status.
D. Correct. Adequate calcium intake is crucial during pregnancy for the development of the baby's bones and teeth. The recommended daily intake of calcium for adolescents during pregnancy is 1,300 milligrams.
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