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 B
Explanation
You have the right to change your mind about this procedure at any time.
Rationale:
- A. "Perhaps you think the ECT is dangerous, but I've seen it have good results." This response is dismissive of the client's concerns and implies that the nurse knows better than the client.
- B. "You have the right to change your mind about this procedure at any time." This response respects the client's autonomy and informs them of their rights.
- C. "Everyone gets a little nervous about this procedure as the time for it approaches." This response minimizes the client's feelings and assumes that they are experiencing normal anxiety.
- D. "Your doctor wouldn't have suggested ECT if they didn't think it would help you." This response shifts the responsibility to the doctor and does not address the client's fears.
Correct Answer is ["B","C","E","F"]
Explanation
The four findings that require follow-up are B, C, E, and F.
Rationale:
- Blood pressure: A normal blood pressure for an adolescent is 110/70 mm Hg. The question does not provide the adolescent's blood pressure, so it cannot be determined if it requires followup or not.
- Capillary refill: A normal capillary refill time is less than 2 seconds. A prolonged capillary refill time indicates impaired blood flow to the extremity, which could be due to vascular injury, compartment syndrome, or shock.
- Pedal pulse: A normal pedal pulse is +2 or +3. A weak pedal pulse (+1) indicates reduced blood flow to the extremity, which could be due to vascular injury, compartment syndrome, or shock.
- Heart rate: A normal heart rate for an adolescent is 60 to 100 beats per minute. The question does not provide the adolescent's heart rate, so it cannot be determined if it requires follow-up or not.
- Skin temperature: A normal skin temperature is warm and dry. A cool skin temperature indicates reduced blood flow to the extremity, which could be due to vascular injury, compartment syndrome, or shock.
- Pain: A pain level of 10 on a scale of 0 to 10 indicates severe pain that needs to be managed with appropriate analgesics and nonpharmacological interventions.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.