A nurse is delegating client care tasks to assistive personnel. Which of the following tasks should the nurse delegate?

Evaluating the healing of an incision

Changing IV tubing

Performing a simple dressing change

Inserting an NG tube

Answer and Explanation

The Correct Answer is B

Choice A reason:
Evaluating the healing of an incision is not necessary because it involves clinical judgment and assessment skills, which are generally beyond the scope of practice for assistive personnel.
Choice B reason:
Changing IV tubing is a task that can often be safely delegated to an assistive personnel (AP) who has been trained and deemed competent to perform this task. It is within the AP's scope of practice and doesn't require clinical judgment or assessment.
Choice C reason:
Performing a simple dressing change involves direct contact with a wound and requires knowledge of aseptic technique and wound care principles. This task is typically performed by licensed nursing personnel.
Choice D reason:
Inserting an NG tube is a complex procedure that requires specialized training and skill. It should be performed by a licensed nurse or another healthcare professional with the appropriate training and competence.

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Correct Answer is B, C, E, D, A

Explanation

B. Provide adequate lighting to inspect the abdomen: Adequate lighting is important to ensure that the nurse can clearly see and assess the client's abdominal area. This step helps identify any visible abnormalities, such as skin changes, scars, masses, or distention.

C. Listen to the abdominal arteries using the bell of a stethoscope: Listening to the abdominal arteries helps the nurse assess blood flow and detect any abnormal vascular sounds, such as bruits or murmurs. This step provides information about vascular health and potential issues related to blood flow.

E. Locate liver and spleen borders by pressing hands 2.5 to 7.5 cm (1 to 3 in) into the abdomen: Palpating and locating the liver and spleen borders help assess the size and position of these organs. It can help identify hepatomegaly (enlarged liver) or splenomegaly (enlarged spleen), which could indicate various underlying conditions.

D.Check for areas of tenderness by pressing fingers 1.3 cm (0.5 in) into the abdomen: Palpating the abdomen for tenderness helps identify areas of discomfort or pain. It can provide information about potential inflammation, organ enlargement, or other sources of discomfort

A. Sodium 140 mEq/L B. Potassium 5.8 mEq/L C. Calcium 9.6 mg/dL D. Magnesium 1.9 mEq/L

Correct Answer is B

Explanation

Choice A reason:

Sodium 140 mEq/L is incorrect because it falls within the normal range (135-145 mEq/L).

Choice B reason:

A potassium level of 5.8 mEq/L is appropriate because it is above the normal range (typically around 3.5-5.0 mEq/L). Elevated potassium levels, known as hyperkalaemia, can lead to serious cardiac disturbances, including arrhythmias or even cardiac arrest. It is important to notify the healthcare provider promptly so that appropriate interventions can be initiated to address the high potassium level.

Choice C reason:

Calcium 9.6 mg/dL is incorrect because it is within the normal range (8.5-10.5 mg/dL).

Choice D reason:

Magnesium 1.9 mEq/L is incorrect because it is within the normal range (1.5-2.5 mEq/L).

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A nurse is delegating client care tasks to assistive personnel. Which of the following tasks should the nurse delegate?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to perform a physical assessment of a client's abdomen. Identify the sequence in which the nurse should perform the following steps. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)

Correct Answer is B, C, E, D, A

Explanation

A nurse is reviewing the medical record for a newly admitted client. Which of the following laboratory values should the nurse report to the provider?

Correct Answer is B

Explanation

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