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 D

Explanation

The correct answer is D. Using two gloved fingers to open the client’s mouth for cleaning.

Choice A rationale:

Lowering the side rail on the side of the bed where the AP will stand is necessary for safe access to the client. However, the AP should ensure the opposite side rail is up to prevent the client from falling.

Choice B rationale:

Using an oral care sponge swab moistened with cool water is an appropriate method for cleaning the mouth of an unconscious client. It helps maintain oral hygiene and comfort.

Choice C rationale:

Wearing clean gloves is essential for infection control and is a standard practice when performing mouth care to protect both the client and the caregiver.

Choice D rationale:

Using two gloved fingers to open the client’s mouth is not recommended as it can cause injury to the caregiver if the client bites down reflexively. Instead, a padded tongue blade should be used to gently open the mouth.

A. Devout practitioners of Buddhism prefer a ritual bath prior to burial. B. Devout practitioners of Islam prefer to have their heads turned toward Mecca at death. C. Devout practitioners of Judaism prefer to be buried 5 days after death. D. Devout practitioners of Hinduism prefer to be buried after death and not cremated.

Correct Answer is B

Explanation

The correct answer is choice B. Devout practitioners of Islam prefer to have their heads turned toward Mecca at death.

This is because Mecca is considered the holiest city in Islam and facing it is a sign of respect and devotion.

Choice A is wrong because devout practitioners of Buddhism prefer to be cremated rather than buried.

Cremation is seen as a way of releasing the soul from the body and preparing for rebirth.

Choice C is wrong because devout practitioners of Judaism prefer to be buried as soon as possible after death, usually within 24 hours.

This is based on the biblical commandment to bury the dead quickly and respect their dignity.

Choice D is wrong because devout practitioners of Hinduism prefer to be cremated after death and not buried.

Cremation is believed to help the soul detach from the body and achieve liberation.

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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 observes assistive personnel (AP) perform mouth care for a client who is unconscious. Which of the following actions by the AP requires intervention by the nurse?

Correct Answer is D

Explanation

A nurse is reinforcing teaching with a newly hired nurse about cultural sensitivity during death and dying. Which of the following information should the nurse include?

Correct Answer is B

Explanation

A nurse is monitoring a client’s oxygen saturation using a pulse oximeter. The client’s oxygen saturation is 88% on 2 L/min of oxygen via nasal cannula. Which of the following actions should the nurse take?

A nurse is collecting data about a client’s oral care. The client wears dentures and reports having mouth sores. The nurse should identify which of the following oral care practices by the client as a possible cause of the mouth sores?

A nurse is reinforcing teaching with a client who has crutches regarding the use of the three-point gait. Which of the following instructions should the nurse include?

A nurse is caring for a client who refuses a prescribed medical procedure. Which of the following actions should the nurse take to act as a client advocate

A nurse is reinforcing teaching with a client about using guided imagery to manage chronic pain. Which of the following statements by the client indicates an understanding of this technique?

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