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 A
Explanation
The nurse should first palpate the abdomen to assess for tenderness and rigidity, which can provide important information about the client's condition. Right lower quadrant pain can be a sign of appendicitis, and abdominal palpation is an important part of the assessment for this condition.
- Administering an antiemetic may help relieve the client's nausea and vomiting, but it is not the first action the nurse should take.
- Offering pain medication may help relieve the client's pain, but it is not the first action the nurse should take.
- Auscultating bowel sounds can provide information about the client's gastrointestinal function, but it is not the first action the nurse should take.
Correct Answer is C
Explanation
If a client reports pain and informs the nurse that pain medications are not an option for managing their pain, the nurse can offer non-pharmacological interventions such as a back massage to help relieve the client's pain. This is an appropriate response by the nurse.
a. Telling the client that the pain medication will work if they just give it a chance is not an appropriate response as it dismisses the client's concerns and preferences.
b. The nurse should not recommend that the client take any herbal remedies without first consulting with the healthcare provider.
d. Asking the client why they think pain medication is not going to help them may be appropriate in some situations, but it is not necessarily the best initial response. The nurse should first offer non- pharmacological interventions to help relieve the client's pain.
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