A nurse is caring for a group of clients. Which of the following tasks should the nurse delegate to an assistive personnel? (Select all that apply.)
Changing a dressing for a client who has a stage 3 pressure injury
Obtaining a signed consent from a client for a screening colonoscopy
Measuring I &0 for a client who is receiving parenteral nutrition
Providing postmortem care for a client who experienced cardiac arrest
Transferring a client from a bed to a chair with a mechanical lift
Correct Answer : D,E
A. Changing a dressing for a client who has a stage 3 pressure injury: Dressing changes for complex wounds require assessment of the wound, evaluation for signs of infection, and clinical judgment to select appropriate interventions. These responsibilities fall within the nurse’s scope of practice and should not be delegated to assistive personnel.
B. Obtaining a signed consent from a client for a screening colonoscopy: Obtaining informed consent involves explaining the procedure, risks, benefits, and answering client questions, which requires nursing knowledge and legal responsibility. This task cannot be delegated to assistive personnel.
C. Measuring I&O for a client who is receiving parenteral nutrition: Monitoring and documenting intake and output for a client receiving parenteral nutrition involves critical interpretation of fluid balance, which may affect electrolyte management and therapy adjustments. This task requires nursing judgment and is not appropriate for delegation.
D. Providing postmortem care for a client who experienced cardiac arrest: Postmortem care is a routine, noninvasive task that does not require nursing judgment. Assistive personnel can perform this task, including cleaning and positioning the body and preparing the client for the family, making it appropriate for delegation.
E. Transferring a client from a bed to a chair with a mechanical lift: Assisting with safe client mobility using a mechanical lift is within the scope of an assistive personnel’s role. This task does not require clinical decision-making but ensures safety and proper technique, making it suitable for delegation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Shellfish allergy: Glucosamine supplements are often derived from shellfish. Clients with a shellfish allergy may experience an allergic reaction if they take glucosamine, making this an important contraindication to assess before recommending the supplement.
B. History of smoking: Smoking does not directly contraindicate glucosamine use. While smoking has other health risks, it does not increase the risk of adverse effects from this supplement.
C. Cardiac dysrhythmia: Glucosamine is not known to cause cardiac dysrhythmias, and a history of dysrhythmias is generally not a contraindication. Standard monitoring is sufficient.
D. Family history of malignant hyperthermia: Malignant hyperthermia is triggered by certain anesthetic agents, not dietary supplements like glucosamine. This family history does not affect the safety of glucosamine intake.
Correct Answer is A
Explanation
A. A 24-year-old male who has a casted femur fracture: Long bone fractures, particularly of the femur, are the most common cause of fat embolism syndrome (FES). Fat globules can enter the bloodstream from the bone marrow, leading to respiratory, neurologic, and dermatologic manifestations. Young adults are at higher risk due to the frequency of high-energy trauma.
B. A 10-year-old female who has an ulnar fracture in an external fixator: FES is rare in small bone fractures such as the ulna, especially in children. The risk is minimal because less marrow fat is released into circulation compared with long bones like the femur.
C. A 45-year-old male who has multiple rib fractures: Rib fractures carry a low risk for FES because they involve flat bones with less marrow fat. The primary complications are respiratory in nature, such as pneumothorax or pulmonary contusion.
D. A 62-year-old female who has vertebral fractures due to osteoporosis: Vertebral fractures in older adults rarely result in FES because the marrow fat released is minimal, and low-energy trauma is usually involved. Other complications, such as spinal cord injury or chronic pain, are more likely.
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