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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["F"]
Explanation
f) Skin surrounding the stoma is reddened and appears irritated.
The information that requires intervention by the nurse is that the skin surrounding the stoma is reddened and appears irritated. This may indicate that the client is experiencing skin irritation or breakdown, which can lead to infection or other complications. The nurse should assess the skin and initiate appropriate interventions to prevent further skin damage.
Options a, b, c, d, e, and g do not necessarily require intervention by the nurse. A pink ileostomy stoma and moderate brown liquid stool drainage are normal findings. The client's refusal to look at the stoma or learn about stoma care may be concerning, but it is not an immediate priority for intervention. An intake of 2,200 mL over 24 hours and a urine output of 650 mL over 24 hours are within normal limits.
Correct Answer is ["A","B","D","E"]
Explanation
The nurse should stop the transfusion, place the client in high-Fowler's position, obtain a prescription for a diuretic, and administer oxygen to the client. These actions can help manage the symptoms of transfusion- associated circulatory overload (TACO), which can occur when a client receives too much fluid too quickly during a blood transfusion.
c. Administering epinephrine is not an appropriate action for managing TACO. Epinephrine is used to treat anaphylaxis, which is a different type of transfusion reaction.
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