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A nurse is delegating care for a client who has right-sided weakness following a cerebrovascular accident. The client coughs when eating and voice becomes hoarse after swallowing. Select the four tasks the nurse should assign to an assistive personnel.

Ambulate the client.

Document the client's urine output.

Assist the client with completing their food menu.

Instruct the client on swallowing techniques.

Obtain the client's vital signs.

Refer the client to the speech language pathologist

Answer and Explanation

Correct Answer : A,B,C,E

Choice A: Ambulate the client

Ambulating the client is a task that can be safely delegated to assistive personnel. The client has right-sided weakness following a cerebrovascular accident, and assistive personnel can help the client move around safely¹.

Choice B: Document the client's urine output

Documenting the client's urine output is another task that can be delegated to assistive personnel. They are trained to measure and record urine output, which is important for monitoring the client's fluid balance¹.

Choice C: Assist the client with completing their food menu

Assistive personnel can also help the client with completing their food menu. This task does not require clinical judgement and can be safely delegated¹.

Choice D: Instruct the client on swallowing techniques

Instructing the client on swallowing techniques should not be delegated to assistive personnel. This task requires specialized knowledge and skills that are beyond the scope of practice for assistive personnel².

Choice E: Obtain the client's vital signs

Obtaining the client's vital signs is a task that can be delegated to assistive personnel. They are trained to accurately measure and record vital signs, which are crucial for monitoring the client's health status¹.

Choice F: Refer the client to the speech language pathologist

Referring the client to the speech language pathologist is not a task that can be delegated to assistive personnel. This decision requires clinical judgement and should be made by the nurse².

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Correct Answer is D

Explanation

Choice A reason: Inflammation noted on the tissue edges of a client's wound is a finding that indicates wound infection, not wound healing. The nurse should monitor the wound for signs of infection, such as increased pain, swelling, warmth, odor, or purulent drainage.

Choice B reason: Increase in serosanguineous exudate from a client's wound is a finding that indicates wound deterioration, not wound healing. The nurse should assess the wound for signs of increased tissue damage, such as bleeding, necrosis, or sloughing.

Choice C reason: Erythema on the skin surrounding a client's wound is a finding that indicates wound irritation, not wound healing. The nurse should evaluate the wound for signs of inflammation, such as redness, heat, or tenderness.

Choice D reason: Deep red color on the center of a client's wound is a finding that indicates wound healing, as it shows the presence of granulation tissue. Granulation tissue is a sign of new tissue growth and blood vessel formation, which are essential for wound healing.

A. Secure the client's restraints with a square knot B. Attach the restraints to the fixed portion of the frame of the client's bed C. Remove the client's restraints every 2 hours D. Allow 1 fingerbreadth between the restraint and the client's wrists

Correct Answer is B

Explanation

A. Secure the client's restraints with a square knot
This is incorrect because square knots are difficult to release in an emergency. Quick-release knots are recommended for safety.

B. Attach the restraints to the fixed portion of the frame of the client's bed
This is correct because attaching restraints to the bed frame ensures they remain stable and do not pose a risk if the bed position changes. Restraints should never be attached to movable parts like side rails, as this can lead to injury.

C. Remove the client's restraints every 2 hours
This is a common practice, but not specific enough for the primary focus of the question. While restraints should be removed periodically to check for circulation, skin integrity, and range of motion, the interval might vary based on institutional policy and patient needs.

D. Allow 1 fingerbreadth between the restraint and the client's wrists
This is incorrect because the proper fit is typically 2 fingers to ensure the restraint is snug but not too tight, preventing circulation issues or injury.

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A nurse is delegating care for a client who has right-sided weakness following a cerebrovascular accident. The client coughs when eating and voice becomes hoarse after swallowing. Select the four tasks the nurse should assign to an assistive personnel.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing pressure ulcers on four clients to evaluate the effectiveness of a change in wound care procedure. Which of the following findings indicates wound healing?

Correct Answer is D

Explanation

A nurse is providing teaching to an assistive personnel (AP) about the application of wrist restraints to a client. Which of the following instructions should the nurse include in the teaching?

Correct Answer is B

Explanation

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