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 C

Explanation

The correct answer is choice C. The client who says “I need to learn how to perform a dressing change on my leg” is indicating an acceptance of the limb loss and a readiness to learn self-care skills.

This is a positive sign of coping and adaptation after an amputation surgery.

Choice A is wrong because the client who says “I am going to have to find someone who can take care of my leg at home” is expressing dependency and denial of the limb loss.

The client needs to be encouraged to participate in self-care activities and rehabilitation.

Choice B is wrong because the client who says “I stay awake at night because I keep thinking about my leg” is experiencing phantom limb sensation, which is a common phenomenon after amputation.

The client may benefit from pain management, distraction techniques, and counseling.

Choice D is wrong because the client who says “I know my family means well, but I don’t want visitors seeing my leg right now” is showing signs of social isolation and low self-esteem.

The client needs emotional support and reassurance from the nurse and family members.

Normal ranges for vital signs after amputation are blood pressure 120/80 mm Hg, pulse 60-100 beats/min, respiratory rate 12-20 breaths/min, and temperature 36.5-37.5°C.

A. “Perform regular isometric exercises.”. B. “Increase your intake of protein.”. C. “Dangle your legs over the side of the bed.”. D. “Use your incentive spirometer.”.

Correct Answer is C

Explanation

The correct answer is choice C. “Dangle your legs over the side of the bed.” This helps prevent orthostatic hypotension, which is a form of low blood pressure that happens when standing after sitting or lying down.

Dangling the legs over the side of the bed allows blood to flow back to the heart and increases blood pressure before standing up.

Choice A is wrong because “Perform regular isometric exercises.” Isometric exercises are muscle contractions without movement, such as squeezing a ball or clenching a fist.

These exercises do not help with orthostatic hypotension because they do not improve blood circulation or blood pressure.

Choice B is wrong because “Increase your intake of protein.” Protein intake does not affect orthostatic hypotension directly.

However, staying hydrated by drinking plenty of fluids can help prevent or manage the condition by maintaining blood volume and blood pressure.

Choice D is wrong because “Use your incentive spirometer.” An incentive spirometer is a device that helps improve lung function after surgery by encouraging deep breathing.

It does not prevent orthostatic hypotension because it does not affect blood pressure or blood flow.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is 2 days postoperative following a below-theknee amputation. Which of the following statements by the client should the nurse identify as indicating an acceptance of the limb loss?

Correct Answer is C

Explanation

A nurse is caring for a client who is postoperative and is preparing to walk for the first time in several days. Which of the following instructions should the nurse give the client to prevent orthostatic hypotension?

Correct Answer is C

Explanation

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