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.
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. *.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Visual disturbances are a less common side effect of risperidone and are not typically considered a priority finding. While they can be a nuisance for the client, they do not pose an immediate threat to the client's life. Other side effects require more immediate attention and intervention from the healthcare provider.
Choice B rationale
Risperidone can cause cardiac side effects such as QT prolongation, which can lead to life-threatening arrhythmias like Torsades de pointes. An irregular pulse is a critical finding that could indicate an underlying cardiac issue and requires immediate evaluation. This is a priority finding for the nurse to report to the provider.
Choice C rationale
Constipation is a common side effect of risperidone due to its anticholinergic properties. While it can cause discomfort, it is not an immediate life-threatening condition. The nurse should address this by encouraging fluid and fiber intake and possibly discussing a stool softener with the provider, but it is not the highest priority.
Choice D rationale
Dry mouth is a common and relatively benign side effect of risperidone. While it can cause discomfort and increase the risk of dental caries, it is not an urgent or life-threatening condition. The nurse can advise the client on strategies to manage this symptom, such as using sugar-free candies or chewing gum. *.
Correct Answer is B
Explanation
Choice A rationale
Antacids containing mint, such as peppermint, can actually worsen the symptoms of GERD. Mint is known to relax the lower esophageal sphincter, which allows stomach acid to reflux into the esophagus more easily. This can increase heartburn and discomfort, so it should be avoided.
Choice B rationale
Chocolate contains methylxanthines, which can decrease the pressure of the lower esophageal sphincter, allowing stomach contents to reflux into the esophagus. This can trigger or worsen GERD symptoms like heartburn and regurgitation. Therefore, clients with GERD should limit or avoid consuming foods containing chocolate to minimize symptom severity.
Choice C rationale
Lying down after eating can exacerbate GERD symptoms because it allows gravity to work against the lower esophageal sphincter, making it easier for stomach acid to flow back into the esophagus. Clients should remain upright for at least 3 hours after a meal to aid digestion and prevent reflux.
Choice D rationale
Citrus fruits are highly acidic and can irritate the already inflamed esophageal lining in a client with GERD, leading to increased pain and discomfort. Consuming acidic foods can worsen heartburn symptoms and should be limited or avoided to manage the condition effectively. *.
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