A nurse is coordinating the care of a group of clients with an assistive personnel (AP). Which of the following tasks should the nurse not assign to the AP?

Measure the intake and output of a client who has received furosemide.

Check a client’s peripheral IV site for redness or swelling.

Assess the pain level of a client who has received acetaminophen.

Reinforcing teaching with a client about crutch-gait walking

None

Answer and Explanation

The Correct Answer is C

- When coordinating the care of a group of clients with assistive personnel (AP), it's important to delegate tasks appropriately based on the AP's scope of practice and training. Here are the tasks that can be assigned to the AP:

Measure the intake and output of a client who has received furosemide: This task involves recording fluid intake and output, which is typically within the scope of practice for an AP, as long as they have been trained in the proper procedure and documentation.

Check a client’s peripheral IV site for redness or swelling: This task involves basic assessment and can be assigned to an AP, as long as they are familiar with the signs of potential complications related to IV sites and have been trained in the facility's protocol for reporting any issues.

Reinforcing teaching with a client about crutch-gait walking: Education and reinforcement of information provided by healthcare professionals can often be delegated to APs, especially if they have received training on the specific topic. However, it's important to ensure that the AP is knowledgeable about crutch-gait walking and the information they are reinforcing.

The task related to assessing pain (e.g., assessing the pain level of a client who has received acetaminophen) should generally be performed by a licensed healthcare provider, such as a nurse. Assessment of pain requires a deeper understanding of the client's pain experience and may involve making clinical decisions related to pain management.

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Correct Answer is A

Explanation

The correct answer is choice A. Evaluate the client’s concerns and communicate them to the provider.

This is because the nurse’s role as a patient advocate is to speak, act or behave in a way that benefits their patient, who may not be able to support or promote their own needs or interests.

The nurse should provide patients with information regarding their diagnoses, prognoses, treatments, and alternatives, and serve as a patient’s voice when necessary.

Choice B is wrong because contacting the unit’s social worker to report the client’s refusal is not an appropriate action for the nurse to take as a patient advocate.

The nurse should respect the patient’s autonomy and right to refuse treatment, and not involve other professionals without the patient’s consent.

Choice C is wrong because asking the client’s partner to find out why the client has refused the procedure is not an appropriate action for the nurse to take as a patient advocate.

The nurse should communicate directly with the patient and not rely on third parties to obtain information or influence the patient’s decision.

Choice D is wrong because explaining the necessity of the procedure to the client is not an appropriate action for the nurse to take as a patient advocate.

The nurse should not impose their own values or opinions on the patient, but rather provide unbiased and factual information and support the patient’s informed choice.

A. Raise the bed to waist level before moving the client. B. Pivot on the foot farthest from the bed when assisting the client into the chair. C. Stand on the client’s stronger side when moving the client into the chair. D. Flex hips and knees when assisting the client to a standing position.

Correct Answer is D

Explanation

The correct answer is choice D. Flex hips and knees when assisting the client to a standing position.

Choice A rationale:

Raising the bed to waist level before moving the client is not recommended because it can increase the risk of falls and injuries. The bed should be at a height that allows the nurse to maintain proper body mechanics and ensure the client’s safety during the transfer.

Choice B rationale:

Pivoting on the foot farthest from the bed when assisting the client into the chair is incorrect. The nurse should pivot on the foot closest to the bed to maintain stability and control during the transfer.

Choice C rationale:

Standing on the client’s stronger side when moving the client into the chair is not the best practice. The nurse should stand on the client’s weaker side to provide support and prevent the client from falling towards their weaker side.

Choice D rationale:

Flexing hips and knees when assisting the client to a standing position is correct. This technique helps the nurse maintain proper body mechanics, reduces the risk of injury, and provides better support to the client during the transfer.

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A nurse is coordinating the care of a group of clients with an assistive personnel (AP). Which of the following tasks should the nurse not assign to the AP?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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