A nurse is coordinating care of a group of clients with an assistive personnel (AP). Which of the following tasks should the nurse assign to the AP?
A. Assess the pain level of a client who has received acetaminophen.
Check a client's peripheral IV site for redness or swelling.
Measure the intake and output of a client who has received furosemide.
Reinforce teaching with a client about crutch-gait walking.
The Correct Answer is C
Choice A rationale
Assessing pain levels is a nursing task requiring clinical judgment, which is beyond the scope of an assistive personnel's duties.
Choice B rationale
Checking an IV site for redness or swelling also requires clinical assessment skills, which are tasks for the nurse.
Choice C rationale
Measuring intake and output is a routine task that can be safely delegated to an assistive personnel. It involves straightforward measurement and recording.
Choice D rationale
Reinforcing teaching about crutch-gait walking requires specific patient education, which falls under the nurse's responsibilities.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Encouraging a partner to eat three large meals each day may not be appropriate in end-of-life care. Clients often have reduced appetite, and small, frequent meals are usually recommended to avoid overwhelming them.
Choice B rationale
Opioids are commonly used in end-of-life care to manage pain and distress. Even if respiratory distress occurs, opioids are not typically restricted, but rather adjusted to balance pain relief and respiratory function.
Choice C rationale
Using an electric blanket can pose safety risks, including burns or electrical hazards, especially if the client is unable to communicate discomfort. Instead, alternative methods such as warm blankets are safer.
Choice D rationale
Assuming the partner can hear even if they do not respond is important. Hearing is believed to be one of the last senses to fade, and speaking to the client can provide comfort and connection.
Correct Answer is ["A","D","E"]
Explanation
Choice A rationale
Pad bony prominences before applying a restraint to prevent skin breakdown and pressure sores. Bony areas are prone to pressure ulcers when subjected to prolonged pressure from restraints.
Choice B rationale
Restraint ends should never be tied to the client's bed rail because it can lead to injury if the bed rail is moved or adjusted. Proper technique involves securing restraints to a part of the bed frame that does not move.
Choice C rationale
A square knot should not be used to secure the client's restraint as it can be difficult to untie in an emergency. Instead, quick-release knots or buckle straps are preferred for safety and rapid removal.
Choice D rationale
Observing the client's skin integrity every 2 hours is crucial to identify any signs of skin irritation, pressure ulcers, or other complications early. Regular checks ensure prompt intervention if issues arise.
Choice E rationale
Ensuring that two fingers can be placed between the restraint and the client helps to maintain proper circulation and comfort, preventing too tight a restraint which can lead to circulatory and nerve damage.
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