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:
"I'm sure it's nothing serious and their appetite will return soon." Is incorrect. This response dismisses the concern without addressing the underlying issue. It might overlook potential reasons for the lack of appetite and could lead to neglecting a serious problem.
Given the concern about the client not eating, the most appropriate response for the nurse to make would be:
Choice B Reason:
"Tell me more about what happens at mealtime." Is correct. This response encourages the child to share specific details about the mealtime routine, any challenges, or reasons behind the lack of eating. It allows the nurse to gather more information, identify potential issues, and offer appropriate guidance or interventions. Understanding the context surrounding the eating habits can help determine the best approach to address the situation effectively.
Choice C Reason:
"Why do you think they're not eating?" is incorrect. While it encourages discussion, this response puts the responsibility on the child to provide explanations that they might not fully understand or be equipped to articulate. It's essential for the nurse to gather information but in a more supportive and guiding manner.
Choice D Reason:
"They may need a feeding tube." Is incorrect. Jumping to a conclusion about a feeding tube without gathering more information or exploring other possibilities could alarm the child unnecessarily. This response could also create unnecessary worry for the child and the family without assessing the situation comprehensively.
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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