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?
Measure the intake and output of a client who has received furosemide.
Reinforce teaching with a client about crutch-gait walking.
Check a client's peripheral IV site for redness or swelling.
Assess the pain level of a client who has received acetaminophen.
The Correct Answer is A
Choice A Reason:
Measuring the intake and output of a client who has received furosemide is correct. This task involves recording and measuring fluid intake and output, which is typically within the scope of practice for assistive personnel. It requires accurate documentation and doesn't involve making clinical judgments.
Choice B Reason:
Reinforcing teaching with a client about crutch-gait walking is incorrect. Teaching and instructing clients about specific medical procedures or techniques usually require specialized knowledge and assessment skills, typically within the nurse's scope of practice.
Choice C Reason:
Checking a client's peripheral IV site for redness or swelling is incorrect. Assessing for redness or swelling at an IV site involves clinical judgment and assessment skills to identify potential complications. This task is better suited for a licensed nurse who can interpret findings and take appropriate action if needed.
Choice D Reason:
Assessing the pain level of a client who has received acetaminophen is incorrect. Assessing pain levels involves subjective interpretation and understanding of pain scales, which generally falls under the scope of licensed healthcare providers who can evaluate and manage pain interventions based on assessments.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A Reason:
Including the family member in providing care for the client is incorrect. While involving the family in care might be helpful for some, not all family members might feel comfortable or capable of participating in direct care during such an emotional and difficult time. Asking their preferences and respecting their boundaries is crucial.
Choice B Reason:
Describing a personal experience with the death of a family member is incorrect. Sharing personal experiences could potentially be inappropriate or overwhelming for the family member. It might inadvertently shift the focus away from the client's needs and emotions.
Choice C Reason:
Asking if they have had prior experience with the death of a family member is correct. This approach allows the nurse to understand the family member's prior experiences with death, providing insights into their understanding, fears, and expectations. It also helps the nurse tailor their support accordingly, acknowledging their emotions and offering assistance that aligns with their comfort level.
Choice D Reason:
Suggesting that the family member contact a grief counselor is incorrect. While grief counseling might be beneficial, suggesting it immediately might not address the family member's immediate need or desire to help in the moment. It's essential to acknowledge their offer to help and offer immediate support or guidance that aligns with their comfort level.
Correct Answer is B
Explanation
Choice A Reason:
The stoma bleeds lightly when touched is incorrect. Some minor bleeding during the initial postoperative period is expected due to surgical trauma. Light bleeding when touched might not be unusual in the immediate days following colostomy placement.
Choice B Reason:
The stoma appears dark in color is correct. A dark-colored stoma could indicate compromised blood supply or ischemia, which is a concerning finding postoperatively. It's crucial to report this change in color promptly to the provider for further evaluation and intervention.
Choice CReason:
The stoma is draining a small amount of liquid stool is incorrect. In the early postoperative period, drainage of liquid stool from the stoma is normal. The digestive system needs time to adapt to the new anatomy created by the colostomy, and initially, the stool consistency might be liquid before it starts to normalize.
Choice DReason:
The stoma protrudes slightly from the abdomen is incorrect. A slightly protruding stoma is a common and expected finding after colostomy surgery. It's often a normal part of the healing process as the stoma settles and adjusts.
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