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 A
Explanation
Choice A rationale
Placing an identification tag on the outside of the client's shroud is essential for proper identification, especially in cases requiring an autopsy. This practice ensures that the deceased person is accurately identified throughout the process and helps prevent any mix-ups or misidentifications.
Choice B rationale
Asking the assistive personnel to document the client's time of death is incorrect as it is the nurse's responsibility to document the time of death accurately in the medical records, not the assistive personnel's duty.
Choice C rationale
Wearing sterile gloves when cleaning the client's body is not necessary. Standard precautions and the use of non-sterile gloves are sufficient for postmortem care unless there are specific reasons requiring sterility, which is uncommon.
Choice D rationale
Removing the client's dentures and giving them to the client's family is incorrect for an autopsy case. Dentures should be left in place to maintain the integrity of the body and to ensure that all personal effects are accurately documented and managed.
Correct Answer is ["A","B","D"]
Explanation
Choice A rationale: The client’s respiratory rate of 10/min is below the normal range (12-20 breaths per minute). This suggests respiratory depression, which can be caused by opioid medications like morphine.
Choice B rationale: The client’s pulse oximetry reading of 88% on room air is lower than the normal range (95%-100%). This indicates hypoxemia, which may be due to respiratory depression from the morphine.
Choice C rationale: Although the blood pressure of 99/46 mm Hg is low, it might be acceptable for this client postoperatively. However, it does not require immediate intervention compared to the other choices.
Choice D rationale: The administration of morphine 10 mg subcutaneously needs further action because the client is showing signs of opioid overdose (e.g., respiratory depression, hypoxemia). This necessitates reassessment and potential adjustment of the medication dosage or frequency.
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