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
- A. This choice is incorrect because forgetting to buy a gift is not an example of dissociation, but rather a sign of poor memory or lack of attention.
- B. This choice is correct because describing the abuse as if it happened to someone else is an example of dissociation, which is a defense mechanism that involves separating oneself from painful or traumatic experiences.
- C. This choice is incorrect because being verbally assertive is not an example of dissociation, but rather a personality trait or a coping skill.
- D. This choice is incorrect because blaming the boss for not getting a promotion is not an example of dissociation, but rather a sign of external locus of control or rationalization.
Correct Answer is C
Explanation
Choice A rationale:
Activating the fire alarm system is the second action the nurse should take after rescuing the individuals in the area.
Choice B rationale:
Obtaining and using a fire extinguisher should only be attempted by personnel trained to do so. Using a fire extinguisher incorrectly can escalate the fire or cause harm to individuals in the vicinity. The priority is to evacuate and let trained personnel handle the fire.
Choice C rationale:
Evacuating clients from the area is an essential and immediate step. Evacuation ensures the safety of everyone in the area, preventing potential harm due to smoke inhalation or fire spread.
Choice D rationale:
Closing the doors and windows on the unit can help contain the fire and prevent its spread. However, this action should be taken after activating the fire alarm system and initiating the evacuation process. Closing doors and windows can buy some time and limit the fire's oxygen supply, but it should not delay the evacuation procedure.
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