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
None
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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Related Questions
Correct Answer is C
Explanation
The correct answer is choice C. Use a filter needle to aspirate the medication.
This is because a filter needle can prevent glass particles from being drawn into the syringe when aspirating medication from an ampule.
Glass particles can cause harm to the patient if injected.
Choice A is wrong because cleansing the tip of the ampule with an alcohol swab after opening is not necessary and may contaminate the medication.
Choice B is wrong because adding 0.5 mL of diluent to the medication may alter the concentration and dosage of the medication.
Choice D is wrong because injecting air into the ampule prior to drawing the medication into a syringe is not required and may create pressure that can cause the ampule to break.
Correct Answer is D
Explanation
The correct answer is choice D. Unequal height of the shoulders.
This is because scoliosis is a condition characterized by sideways curvature of the spine that can cause asymmetry of the shoulders, shoulder blades, and hips.
A scoliosis screening is a test that checks for this asymmetry by having the child bend forward from the waist and looking for any prominence of the rib cage or the spine.
Choice A is wrong because expansion of the upper intercostal spaces is not a sign of scoliosis, but rather a sign of hyperinflation of the lungs due to conditions such as asthma or emphysema.
Choice B is wrong because increased convex curve of the cervical spine is not a sign of scoliosis, but rather a sign of kyphosis, which is an excessive outward curvature of the upper spine.
Choice C is wrong because increased concave curve of the thoracic spine is not a sign of scoliosis, but rather a sign of lordosis, which is an excessive inward curvature of the lower spine.
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