A nurse is assisting with the care of a group of clients during a mass casualty event. Which of the following tasks should the nurse assign to an assistive personnel (AP)?

Respond to family members about a client's condition.

Determine which clients should be seen first.

Clean and dress client abdominal wounds.

Take vital signs on clients as they are admitted.

Answer and Explanation

The Correct Answer is D

Choice A reason: Responding to family requires clinical judgment and communication skills beyond AP scope. Nurses handle this in mass casualty for accuracy.

Choice B reason: Triage prioritization needs nursing assessment skills, not AP training. Determining care order is a licensed responsibility in emergencies like this.

Choice C reason: Cleaning and dressing wounds involves sterile technique and assessment, outside AP scope. Nurses perform this in mass casualty settings.

Choice D reason: Taking vital signs is within AP scope, providing data for nurse triage. It’s a routine task, safely assigned in a mass casualty event.

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Correct Answer is D

Explanation

Choice A reason: Releasing restraints every 4 hours lacks context; policy requires 2-hour checks with release if safe. Scientifically, this risks neglect, as frequent assessment ensures circulation and safety, making it less precise than behavior documentation.

Choice B reason: Hourly checks are good but not the action specified; 15-minute intervals are standard for restraints. Scientifically, this underestimates risk monitoring needs, as behavior justification is a legal and clinical priority over timing alone.

Choice C reason: Client consent isn’t required for restraints in emergencies; provider orders suffice. Scientifically, imminent harm overrides autonomy, and consent isn’t feasible mid-crisis, making this impractical and misaligned with restraint protocols.

Choice D reason: Documenting behavior justifies restraints, ensuring legal and ethical use for safety. Scientifically, this aligns with standards, as specific actions (e.g., aggression) validate intervention, providing a clinical basis critical for care continuity and review.

A. Encourage the client to use the overbed trapeze. B. Maintain abduction of the client’s residual limb with a pillow. C. Caution the client to avoid a prone position while in bed. D. Keep a loose, absorbent dressing over the client’s surgical site.

Correct Answer is A

Explanation

Choice A reason: Using a trapeze builds upper body strength, aiding transfers and mobility post-amputation. Scientifically, this promotes independence by enhancing muscle power for prosthetic use, aligning with rehabilitation goals to restore function and reduce reliance on others early in recovery.

Choice B reason: Abduction with a pillow prevents adduction contractures but doesn’t directly enhance mobility. It’s passive, not active, support. Scientifically, while useful, it lacks the progressive impact of strength training, making it secondary to fostering independence in amputation care.

Choice C reason: Avoiding prone position is outdated; prone lying prevents hip flexion contractures, aiding mobility. Scientifically, this caution hinders rehabilitation, as stretching the hip flexors supports prosthetic alignment and walking, contradicting progression toward independence.

Choice D reason: Loose dressings don’t promote mobility; tight, controlled dressings reduce edema for prosthetic fitting. Scientifically, this delays healing and strength-building, as proper wound management, not loose coverage, supports physical progression in amputation recovery.

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A nurse is assisting with the care of a group of clients during a mass casualty event. Which of the following tasks should the nurse assign to an assistive personnel (AP)?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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