A nurse is delegating client care to an assistive personnel (AP). Which of the following tasks should the nurse assign to the AP?
A. Administering vaginal cream to a client who has a vaginal infection.
Providing postmortem care for a client who has just died.
Suctioning a tracheostomy for a client who has a recent head injury.
Changing a peripheral IV dressing for a client who is postoperative.
The Correct Answer is B
Choice A rationale
Administering vaginal cream is a medication administration task requiring knowledge and skills within the licensed nurse's scope of practice. Assistive personnel (AP) are not authorized to perform this procedure due to the potential for complications and the need for clinical judgment.
Choice B rationale
Providing postmortem care is a task that AP can perform as it involves basic care activities, such as bathing and positioning, which do not require specialized nursing skills. This allows the nurse to focus on more complex patient needs.
Choice C rationale
Suctioning a tracheostomy is a procedure that requires clinical assessment and intervention skills. Due to the potential for complications, it is within the licensed nurse's scope of practice, not the AP's.
Choice D rationale
Changing a peripheral IV dressing involves assessment skills and requires sterile technique to prevent infection. This task is beyond the scope of practice for AP and should be performed by a licensed nurse.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
A small amount of liquid stool draining from the stoma is expected during the early postoperative period following colostomy placement. This indicates that the stoma is functioning and passing waste as intended.
Choice B rationale
The stoma protruding slightly from the abdomen, known as stoma protrusion or eversion, is a common and normal finding. It indicates that the stoma is correctly positioned and healing properly.
Choice C rationale
A dark-colored stoma is a concerning sign that indicates compromised blood flow to the stoma tissue, potentially leading to necrosis. This requires immediate medical attention to address the underlying cause and prevent further complications.
Choice D rationale
Light bleeding from the stoma when touched is normal in the immediate postoperative period. The stoma tissue is highly vascular, and minor bleeding is expected as it heals and forms new tissue connections.
Correct Answer is A
Explanation
Choice A rationale
Asking if there are any problems taking care of feet directly assesses the client’s ability to perform foot self-hygiene. It opens up discussion about specific difficulties the client may face, such as flexibility, vision, or dexterity issues.
Choice B rationale
Asking if the client goes barefoot at home is related to foot safety but does not directly assess their ability to perform foot self-hygiene. It's important for preventing injuries and infections, especially in clients with diabetes.
Choice C rationale
Inquiring about foot swelling helps identify potential complications related to diabetes but does not address the client's ability to perform foot self-care.
Choice D rationale
Asking about problems with ingrown toenails is specific to a common issue in diabetic foot care but does not provide a comprehensive assessment of the client’s ability to maintain foot hygiene.
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