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 D
Explanation
Choice A Reason:
Adhesive tape is incorrect. Adhesive tape is commonly used for securing dressings or medical devices, but it may not be the primary supply needed for managing a stage 4 pressure injury. Wound care for a stage 4 pressure injury often involves specialized dressings, cleansing solutions, and applicators rather than adhesive tape alone.
Choice B Reason:
Tongue depressor is incorrect. A tongue depressor is typically used for oral examinations or to apply topical treatments to the mouth. It's not a standard supply for managing a stage 4 pressure injury, which requires specific wound care supplies designed for wound cleaning and dressing application.
Choice C Reason:
Syringe is incorrect. While syringes are versatile tools used in various medical procedures, in the context of managing a stage 4 pressure injury, their primary use might be for administering medications or irrigation solutions rather than being the essential supply for wound care in this specific instance.
For a client with a stage 4 pressure injury, the nurse should obtain supplies that are suitable for wound care. Among the options provided, the most appropriate supply is:
Choice D Reason:
Cotton-tipped applicator is correct. A cotton-tipped applicator can be used for wound cleaning and dressing application for a stage 4 pressure injury. It allows for gentle cleaning of the wound and application of topical treatments while minimizing trauma to the wound area.
Correct Answer is A
Explanation
Choice A Reason:
Chlorine bleach is correct. Chlorine bleach is an effective disinfectant against bloodborne pathogens. It's recommended for cleaning surfaces contaminated with blood spills because it can destroy various microorganisms, including bacteria and viruses. However, it's essential to follow proper dilution guidelines and safety precautions when using bleach.
Choice B Reason:
Chlorhexidine gluconate is incorrect. While chlorhexidine gluconate is an antiseptic commonly used for skin disinfection before medical procedures or as a surgical scrub, it's not typically used for cleaning blood spills on surfaces. Its primary application is for skin disinfection, not environmental surface cleaning.
Choice C Reason:
Hydrogen peroxide is incorrect. Hydrogen peroxide is a mild antiseptic that can disinfect wounds or clean certain surfaces. However, it might not be as effective as chlorine bleach in dealing with blood spills. It's generally used more for superficial wound cleaning rather than for disinfecting large contaminated surfaces.
Choice D Reason:
Isopropyl alcohol is incorrect. Isopropyl alcohol is a commonly used disinfectant for surfaces, but when it comes to blood spills, it might not be as effective as chlorine bleach. While it can kill some pathogens, its efficacy against certain bloodborne pathogens may be limited compared to bleach.
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