A nurse is caring for residents at a long-term care facility following a tornado. Which of the following tasks should the nurse delegate to an assistive personnel?
Determine which clients need priority medical treatment.
Answer questions from area residents who have health concerns.
Perform CPR for a client who is not breathing.
Complete distal capillary refill checks for a client who has an open leg wound.
The Correct Answer is C
A) Determine which clients need priority medical treatment: This task requires clinical judgment and assessment skills beyond the scope of practice for assistive personnel. Nurses are responsible for assessing clients' needs during emergencies and determining priority for medical treatment based on the severity of their conditions.
B) Answer questions from area residents who have health concerns: While it's important to provide information and support to those affected by the tornado, answering questions about health concerns requires knowledge and expertise in healthcare that is typically within the nurse's scope of practice. Nurses should address inquiries and provide education to ensure the well-being of the community.
C) Perform CPR for a client who is not breathing: This task can be delegated to assistive personnel if they are trained and competent in CPR. In emergencies such as cardiac arrest, prompt initiation of CPR can be life-saving. However, it's crucial to ensure that the assistive personnel are properly trained and certified in CPR before delegating this task.
D) Complete distal capillary refill checks for a client who has an open leg wound: While assessing capillary refill is an important aspect of wound care, performing this task for a client with an open leg wound requires specialized knowledge and skills in wound assessment and management. It falls within the scope of nursing practice and should not be delegated to assistive personnel.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Answer: D. Raisin toast
Rationale:
A. Soft-serve ice cream:
While soft-serve ice cream may seem appealing due to its mild taste and smooth texture, it can be high in sugar and fat, which might not be well-tolerated by patients experiencing chemotherapy-induced nausea. Heavy or rich foods can exacerbate nausea, making them less suitable for these clients.
B. Hot tea:
Hot tea can be soothing, but for individuals experiencing nausea, the warmth might not be well-received. Additionally, certain teas can contain caffeine, which may not be advisable for those undergoing chemotherapy, as it can sometimes exacerbate dehydration or jitters.
C. String cheese:
String cheese is a dairy product that can be heavy for some patients, particularly those experiencing nausea from chemotherapy. Dairy may cause gastric discomfort, and many patients may prefer lighter, less greasy options when feeling nauseous.
D. Raisin toast:
Raisin toast is a suitable choice as it is light, easy to digest, and contains carbohydrates that can help settle the stomach. The raisins add some natural sweetness without being overly rich, making it a good option for someone experiencing chemotherapy-induced nausea. This selection demonstrates an understanding of dietary choices that may be better tolerated during episodes of nausea.
Correct Answer is ["A","B","C","D"]
Explanation
A) Assist in checking a unit of packed RBCS to administer to a client:
Assisting in checking a unit of packed red blood cells (RBCs) for transfusion is within the nurse's scope of practice. Nurses are responsible for verifying blood products before administration, ensuring compatibility, proper labeling, and appropriate handling to prevent transfusion reactions.
B) Regulate the client's infusion pump after initiating a heparin drip infusion:
Regulating the client's infusion pump after initiating a heparin drip infusion falls within the nurse's scope of practice. Nurses commonly administer and monitor intravenous medications, including heparin drips, and are responsible for regulating the infusion pump to deliver the medication at the prescribed rate.
C) Teach a client about hemodialysis:
Teaching a client about hemodialysis is within the nurse's scope of practice. Patient education is a fundamental aspect of nursing care, and nurses often provide information to clients and their families about various healthcare procedures, treatments, and self-care management, including hemodialysis.
D) Create a plan of care for a client's discharge:
Creating a plan of care for a client's discharge is within the nurse's scope of practice. Nurses are involved in discharge planning, which includes coordinating with the healthcare team, assessing the client's needs, providing education about post-discharge care, arranging follow-up appointments, and ensuring a smooth transition to the next level of care or home.
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