A nurse is caring for four clients. Which of the following tasks should the nurse delegate to an assistive personnel (AP)?
Evaluate dietary intake for a client who has anorexia.
Measure the vital signs of a client who just returned from the PACU
Arrange the lunch tray for a client who has a hip fracture.
Assess I&O for a client who is receiving dialysis.
The Correct Answer is C
A. Incorrect. Evaluating dietary intake requires nursing judgment and knowledge of nutrition and eating disorders. This task should not be delegated to an AP.
B. Incorrect. Measuring vital signs of a postoperative client requires nursing assessment and monitoring for complications. This task should not be delegated to an AP.
C. Correct. Arranging the lunch tray for a client who has a hip fracture is a routine task that does not require nursing skills or judgment. This task can be delegated to an AP.
D. Incorrect. Assessing I&O for a client who is receiving dialysis requires nursing knowledge of fluid and electrolyte balance and renal function. This task should not be delegated to an AP.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Clean the mouthpiece with warm water every 2 weeks. This is incorrect because the mouthpiece should be cleaned with warm water at least once a week, or more often if used frequently, to prevent bacterial growth and contamination.
B. Wait 10 seconds between inhalations. This is incorrect because the recommended time interval between inhalations is 1 minute, not 10 seconds, to allow adequate absorption of the medication and prevent overdose or side effects.
C. Take a quick inhalation when pressing the dispenser. This is incorrect because a quick inhalation can cause poor coordination of hand-mouth movement and result in less medication reaching the lungs. The nurse should instruct the child to take a slow, deep inhalation when pressing the dispenser, hold their breath for 10 seconds, and exhale slowly.
D. Take the medication 15 min before playing sports. This is correct because albuterol is a short-acting bronchodilator that can prevent exercise-induced bronchospasm. The nurse should teach the child to take the medication before engaging in physical activity that can trigger asthma symptoms, such as sports, cold weather, or allergens.
Correct Answer is ["A","B","C"]
Explanation
A. Assess peripheral circulation hourly. This is correct because clients with SCD are at risk of vaso-occlusive crisis, which can impair blood flow to the extremities and cause tissue ischemia and necrosis. The nurse should monitor for signs of poor circulation such as pallor, coolness, numbness, or pain.
B. Assess the client's mouth every 8 hr. This is correct because clients with SCD are prone to oral ulcers, infections, and dental problems due to chronic anemia and reduced oxygen delivery to the oral mucosa. The nurse should inspect the mouth for lesions, bleeding, inflammation, or infection and provide oral hygiene as needed.
C. Use humidification with oxygen therapy. Administer IV fluids. This is correct because clients with SCD need adequate hydration and oxygenation to prevent sickling of red blood cells and further complications. Humidification helps moisten the airways and prevent dehydration of the mucous membranes. IV fluids help maintain fluid and electrolyte balance and reduce blood viscosity.
D. Raise the knee position on the client's bed. This is incorrect because this can impede venous return and worsen peripheral circulation. The nurse should keep the client's extremities in a neutral position and avoid tight or restrictive clothing or devices.
E. Use an automated blood pressure cuff on the client's arm. Prepare for platelet transfusion. This is incorrect because this can cause mechanical trauma to the arm and trigger a vaso-occlusive crisis. The nurse should use a manual blood pressure cuff and avoid applying pressure to the arm. Platelet transfusion is not indicated for clients with SCD unless they have thrombocytopenia or bleeding.
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