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.

Answer and Explanation

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.

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Correct Answer is ["A","C"]

Explanation

Explanation

Choice A Reason:

A client receives burns from a heating pad is correct. Any injury or harm caused to a client due to a medical device or equipment should be documented in an incident report for evaluation and review to prevent future incidents.

Choice B Reason:

A client's visitor becomes dizzy and faints in the client's room is incorrect. While this event might prompt the nurse to provide immediate assistance and seek medical attention for the visitor, it doesn't typically fall under the purview of an incident report unless it results from an issue within the healthcare facility.

Choice C Reason:

A client becomes disoriented and falls out of bed is correct. Falls resulting in injury or harm to the client, especially due to disorientation, should be documented to assess potential preventive measures and ensure appropriate care.

Choice D Reason:

A client reports being dissatisfied with the temperature of the meals provided is incorrect. Client dissatisfaction with meal temperature is an important concern, but it's generally addressed through communication and service improvement rather than being documented in an incident report unless it poses a risk to the client's health (e.g., if the food was excessively hot, causing harm).

A. Apply clean gloves. B. Ask the client to take a deep breath. C. Instill 50 mL of air into the tube. D. Pinch and withdraw the tube. E. Disconnect the tube from the suction device.

Correct Answer is E,C,B,D,A

Explanation

E. Disconnect the tube from the suction device:

Before starting the removal process, it's essential to disconnect the tube from any suction to prevent discomfort or injury to the client during removal.

C. Instill 50 mL of air into the tube:

Instilling air into the tube helps clear any residual contents and lubricates the tube, making it easier and more comfortable to remove.

B. Ask the client to take a deep breath:

Instructing the client to take a deep breath helps relax the throat and upper esophageal muscles, making the removal process smoother and potentially less uncomfortable.

D. Pinch and withdraw the tube:

Withdrawing the tube while the client holds their breath aids in a controlled removal, minimizing discomfort or risk of aspiration.

A. Apply clean gloves:

Lastly, applying clean gloves ensures infection control and maintains cleanliness during the removal process, preventing any potential contamination.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a group of clients. For which of the following situations should the nurse complete an incident report? (Select all that apply.)

Correct Answer is ["A","C"]

Explanation

A nurse is preparing to remove an NG tube for a client who is postoperative following colon surgery. In which order should the nurse perform the following steps? (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)

Correct Answer is E,C,B,D,A

Explanation

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