A nurse is caring for a group of clients and identifying what tasks she can delegate to an assistive personnel (AP). Which of the following tasks should the nurse delegate to an AP?

Administer a glycerin suppository to a client.

Provide home care instructions to a client's family member.

Suction a client's newly inserted tracheostomy.

Perform rescue breathing for a client who becomes unresponsive.

Answer and Explanation

The Correct Answer is D

Choice A rationale

Administering a suppository is considered a medication administration task, which requires a licensed nurse to perform. This task involves critical thinking and a solid understanding of anatomy, physiology, and pharmacology, as well as the potential for adverse reactions. Therefore, this cannot be delegated to an assistive personnel (AP), whose scope of practice does not include medication administration.

Choice B rationale

Providing home care instructions is part of client education, which is a key responsibility of a licensed nurse. This task requires a thorough understanding of the client's condition, treatment plan, and the ability to assess their learning needs. An AP is not trained to assess, plan, or implement teaching plans for clients, so this task is outside their scope of practice.

Choice C rationale

Suctioning a newly inserted tracheostomy is a skilled and invasive procedure that carries a high risk of complications, such as hypoxemia, trauma, or infection. This procedure requires a nurse's professional judgment and a clear understanding of sterile technique. The AP's role is to provide basic care, not to perform such complex and high-risk procedures.

Choice D rationale

Performing rescue breathing, or cardiopulmonary resuscitation (CPR), is an emergency procedure that falls within the scope of an AP's training. All healthcare workers, including APs, are required to have a basic life support certification. In a medical emergency, every staff member is expected to perform basic life-saving measures, such as rescue breathing, to prevent further client harm. *.

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Correct Answer is B

Explanation

Choice A rationale

Diarrhea is a common side effect of clozapine, a second-generation antipsychotic medication. It is usually a mild to moderate symptom and does not typically warrant immediate reporting to the provider unless it is severe, persistent, or accompanied by other concerning symptoms like dehydration. It can often be managed with dietary adjustments or over-the-counter antidiarrheal medications, and it does not usually indicate a serious or life-threatening adverse reaction.

Choice B rationale

A fever in a client taking clozapine is a critical finding that must be immediately reported to the provider. Fever can be an early symptom of agranulocytosis, a severe and potentially fatal adverse effect characterized by a dangerously low white blood cell count. Agranulocytosis makes the client highly susceptible to severe infections. A fever may also indicate the onset of neuroleptic malignant syndrome, another serious and life-threatening condition.

Choice C rationale

Polyuria, which is excessive urination, can be a symptom of various conditions but is not a primary concern or contraindication for clozapine administration. It can be associated with increased fluid intake due to xerostomia (dry mouth), a common side effect of clozapine. It does not typically indicate a severe, life-threatening adverse effect like agranulocytosis or neuroleptic malignant syndrome, and thus does not require immediate reporting.

Choice D rationale

Diaphoresis, or excessive sweating, is a frequent side effect of clozapine. It is often related to the drug's anticholinergic effects and thermoregulatory dysfunction. While it can be uncomfortable for the client and may require management, it is not an immediate sign of a life-threatening condition like agranulocytosis or neuroleptic malignant syndrome. Therefore, it does not typically require an immediate report to the provider. *.

A. Ensure that the side rails are up on the client's bed. B. Ambulate the client every 4 hours. C. Check the fetal heart rate twice daily. D. Provide the client with a low-protein diet.

Correct Answer is A

Explanation

Choice A rationale

Severe preeclampsia is characterized by high blood pressure, often accompanied by seizures (eclampsia). The client is at high risk for seizures, which can cause falls and injury. Ensuring the side rails are up is a critical safety measure to protect the client from falling out of bed during a seizure episode. This precaution is part of seizure protocols and is essential for client safety in this high-risk condition.

Choice B rationale

Ambulation is contraindicated for clients with severe preeclampsia. They are at high risk for seizures and should be on strict bed rest to minimize physical activity and stress, which can elevate blood pressure and increase the risk of a seizure. Bed rest also helps to improve placental perfusion, which is often compromised in preeclampsia.

Choice C rationale

In a client with severe preeclampsia, fetal well-being is a major concern. The client should have continuous or frequent fetal monitoring, not just twice daily. The compromised placental perfusion can lead to fetal distress, and frequent monitoring, such as nonstress tests or biophysical profiles, is necessary to detect any signs of distress and intervene promptly.

Choice D rationale

A low-protein diet is not recommended for a client with severe preeclampsia. Preeclampsia often causes proteinuria, a loss of protein in the urine, which can lead to low serum albumin levels. A high-protein diet is often encouraged to replace the lost protein and maintain oncotic pressure, which helps to reduce edema.

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A nurse is caring for a group of clients and identifying what tasks she can delegate to an assistive personnel (AP). Which of the following tasks should the nurse delegate to an AP?

Nursing Test Bank

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