A nurse is assisting with the plan of care for four clients. Which of the following tasks should the nurse assign to an assistive personnel (AP)?

Ensure a client can use crutches before discharge.

Check a client's ability to swallow following a stroke.

Obtain a client's pain rating prior to physical therapy.

Assist a client to get out of bed after a breathing treatment.

Answer and Explanation

The Correct Answer is D

A: Incorrect. Ensuring a client can use crutches before discharge requires clinical judgment and skilled assessment, so it should not be delegated to assistive personnel.
B: Incorrect. Checking a client's ability to swallow following a stroke involves assessing the client's airway and potential risk of aspiration, which is a complex nursing task and should not be delegated to assistive personnel.
C: Incorrect. Obtaining a client's pain rating prior to physical therapy requires understanding the client's pain and its management, which should not be delegated to assistive personnel.
D: Correct. Assisting a client to get out of bed after a breathing treatment can be safely delegated to assistive personnel. It involves helping the client move, which is within the scope of their training.

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Free Nursing Study Resources

Correct Answer is A

Explanation

A. Administer an analgesic 30 min before starting the procedure: Correct. Before performing wound irrigation, it is essential to provide pain relief to the client. Administering an analgesic 30 minutes before the procedure will help manage pain during wound irrigation.
B. Hold the syringe 5 cm (2 in) above the upper end of the wound: This action does not contribute to proper wound irrigation. The nurse should direct the irrigation solution to the wound site to cleanse it effectively.
C. Place the irrigation solution in a basin of cool water: Using cool water is not the best practice for wound irrigation. The irrigation solution should be at room temperature or a temperature specified by the healthcare provider.
D. Perform the wound irrigation with a 10mL syringe with an angiocatheter: Wound irrigation typically requires a larger volume of fluid to adequately cleanse the wound. A 10mL syringe may not be sufficient, and using an angiocatheter is not appropriate for wound irrigation. A larger syringe or irrigation solution bag with an appropriate wound irrigation tool is usually used.

A. Check that the restraint is tied to a fixed frame of the bed. B. Pad bony prominences on the wrist. C. Remove the restraint every 4 hr to allow movement. D. Tie the restraint with a knot that will tighten when pulled.

Correct Answer is B

Explanation

A. Check that the restraint is tied to a fixed frame of the bed: Restraints should never be tied to the side rails or a fixed frame of the bed, as this can lead to serious injuries. Restraints should be secured to the bed frame using quick-release ties to ensure safety.
B. Pad bony prominences on the wrist: Correct. Padding bony prominences on the wrist is an important step in the use of restraints to prevent skin breakdown and pressure injuries.
C. Remove the restraint every 4 hr to allow movement: While repositioning and releasing restraints periodically is essential for the client's comfort and safety, it is not appropriate to remove wrist restraints entirely every 4 hours, as they were prescribed for a specific purpose.
D. Tie the restraint with a knot that will tighten when pulled: Restraints should never be tied with a knot that can tighten when pulled, as this can cause harm to the client and restrict blood flow. Restraints should be secured using quick-release ties to allow for easy removal in
emergencies.

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A nurse is assisting with the plan of care for four clients. Which of the following tasks should the nurse assign to an assistive personnel (AP)?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is planning to perform wound irrigation for a client who has a large abdominal wound. Which of the following actions should the nurse plan to take?

Correct Answer is A

Explanation

A nurse is contributing to a plan of care for a client who has a new prescription for a wrist restraint. Which of the following actions should the nurse include in the plan?

Correct Answer is B

Explanation

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A nurse is preparing to transfer a client from an acute care facility to a long-term care facility. Which of the following information should the nurse plan to include in the transfer report?

A nurse is reinforcing preoperative teaching with a client about how to turn, cough, and deep breathe. Which of the following statements by the client indicates an understanding of the teaching?

A nurse at a long-term care facility is caring for a client who is alert. Which of the following actions should the nurse take to protect the client's privacy?

A nurse is reinforcing teaching with a client about the use of crutches. Which of the following actions by the client indicates an understanding of the teaching?