A nurse is caring for a client who has a chest tube following thoracic surgery. Which of the following tasks should the nurse delegate to an assistive personnel?
Monitor the characteristics of the client's chest tube drainage.
Evaluate the client's response to pain medication.
Teach deep breathing and coughing to the client.
Assist the client to select food choices from the menu.
The Correct Answer is D
When caring for a client who has a chest tube following thoracic surgery, the nurse can delegate the task of assisting the client to select food choices from the menu to an assistive personnel. This task is within the scope of practice of an assistive personnel and does not require the specialized knowledge or judgment of a nurse.
Option a is incorrect because monitoring the characteristics of the client's chest tube drainage requires specialized knowledge and should not be delegated.
Option b is incorrect because evaluating the client's response to pain medication requires specialized knowledge and should not be delegated.
Option c is incorrect because teaching deep breathing and coughing to the client requires specialized knowledge and should not be delegated.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
When completing a dressing change on a client who has a surgical wound drain, the nurse should use a separate, sterile swab for each stroke when cleaning the wound. This helps to prevent the spread of infection and ensures that the wound is properly cleaned.
Option b is incorrect because the nurse should first clean the incision and then clean the drain site.
Option c is incorrect because the nurse should don sterile gloves before cleaning the wound.
Option d is incorrect because the nurse should not cut a 4 x 4 piece of gauze to place around the drain site; instead, the nurse should use a pre-cut drain sponge.
Correct Answer is D
Explanation
A. Palpate the abdomen: Palpating the abdomen before auscultating bowel sounds could potentially alter the findings by stimulating peristalsis or causing discomfort in the client, particularly in cases of appendicitis or other acute abdominal conditions.
B. Administer an antiemetic:A thorough assessment, including auscultation of bowel sounds, is needed first to rule out conditions like a bowel obstruction or paralytic ileus where antiemetics may be contraindicated.
C. Offer pain medication:Pain medication can mask symptoms and interfere with the nurse's or physician's ability to accurately assess the underlying cause of the client's symptoms, such as appendicitis.
D. Auscultate bowel sounds:Auscultating bowel sounds is the first action the nurse should take because it is a non-invasive assessment that can provide critical information. It helps determine if bowel sounds are present, hyperactive, hypoactive, or absent, which can guide further interventions and diagnostic steps.
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