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 B
Explanation
Choice A Reason:
"Aren't you interested in learning how to perform this test?" is incorrect. This response might come across as accusatory or judgmental, potentially making the client feel uncomfortable or defensive, further hindering communication.
Choice B Reason:
"Let's talk about what you're thinking." Is correct. This response acknowledges the client's distraction and aims to understand and address their thoughts or concerns that might be hindering their focus. It invites the client to express any worries or questions they might have, allowing the nurse to provide reassurance or clarification.
Choice C Reason:
"I'll discuss this with your partner instead." Is incorrect. Redirecting the conversation to the client's partner without understanding the client's concerns directly could undermine the client's autonomy and miss the opportunity to address their needs.
Choice D Reason:
"Is this something you think you can do?" is incorrect. While this question aims to assess the client's confidence, it might not effectively address the underlying reason for the client's distraction or encourage open communication about their concerns.
Correct Answer is D
Explanation
Choice A Reason:
Placing the bed in the lowest position before logrolling the client is incorrect. Lowering the bed position isn't directly related to the safety or comfort of the client during logrolling. It's more important to focus on proper body alignment and support for the surgical site.
Choice B Reason:
Placing the client in semi-Fowler's position prior to logrolling is incorrect. Semi-Fowler's position (a reclined position with the head of the bed elevated at a 30-45-degree angle) might be used for comfort, but it's not specifically necessary before logrolling, which is a technique used to move the client while maintaining spinal alignment.
Choice C Reason:
Placing the client's arms above her head prior to logrolling is incorrect. Placing the client's arms above the head isn't typically necessary or recommended before logrolling a postoperative client. It's crucial to prioritize maintaining proper body alignment and minimizing stress on the surgical site during movement.
Choice D Reason:
Placing a pillow between the client's legs prior to logrolling is correct. This action helps maintain proper alignment of the spine and reduces pressure on the surgical site during logrolling. Placing a pillow between the legs provides support and helps prevent excessive twisting or stress on the back.
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