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

It's common practice to check blood pressure in both arms when there is a significant discrepancy in blood pressure readings between the arms. This discrepancy could be due to factors like arterial blockages or other conditions. By measuring the blood pressure in the other arm, the nurse can confirm whether the high blood pressure is consistent on both sides or if there was an issue with the initial measurement. This step helps provide a more accurate assessment of the client's blood pressure.

- The other options are not appropriate at this stage:

Deflating the cuff faster may not resolve the issue and could lead to inaccurate measurements.

Requesting a prescription for an antihypertensive medication should only be done after confirming the blood pressure is consistently elevated and under the direction of a healthcare provider.

Using a narrower cuff is not indicated in this situation. It's more important to assess the other arm's blood pressure to identify any discrepancies.

A. A client is unable to afford the physical therapy that the provider recommends. B. A client reports being dissatisfied with the temperature of the meals provided. C. A client’s visitor becomes dizzy and faints in the client’s room. D. A client receives burns from a heating pad. E. A client becomes disoriented and falls out of bed.

Correct Answer is ["C","D","E"]

Explanation

The correct answer is choice C, D, and E.

Choice A rationale:A client being unable to afford physical therapy is a financial issue, not an incident that affects patient safety or care quality. This situation should be addressed through social services or financial counseling, not an incident report.

Choice B rationale:A client being dissatisfied with meal temperature is a service quality issue, not a safety incident. This should be reported to the dietary department or patient services for resolution, not through an incident report.

Choice C rationale:A client’s visitor becoming dizzy and fainting in the client’s room is an incident that affects the safety of the visitor. An incident report should be completed to document the event, the visitor’s condition, and any actions taken to provide care or prevent future occurrences.

Choice D rationale:A client receiving burns from a heating pad is a safety incident that directly affects the client’s well-being. An incident report should be completed to document the injury, the circumstances leading to the burn, and any immediate care provided.

Choice E rationale:A client becoming disoriented and falling out of bed is a significant safety incident. An incident report should be completed to document the fall, the client’s condition, and any interventions implemented to prevent future falls.

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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

A nurse on a medical-surgical unit is collecting data from a client who is postoperative following abdominal surgery. The client’s BP was 126/72 mm Hg 15 min ago. The nurse now finds that the client’s BP is 176/96 mm Hg. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

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Correct Answer is ["C","D","E"]

Explanation

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