A nurse is delegating tasks for an assistive personnel (AP) to perform for a client who is 1-day postoperative following cardiac surgery. Which of the following tasks should the nurse perform herself?

Helping the client into the shower

Ambulating the client in the hallway

Measuring vital signs

Removing the sternal dressing

Answer and Explanation

The Correct Answer is D

A. Helping the client into the shower: This task can be safely delegated to an assistive personnel (AP). The AP can help the client with activities of daily living such as showering, as long as the client is stable and does not require close monitoring.

B. Ambulating the client in the hallway: This task can also be delegated to an AP. Assisting with ambulation is within the scope of practice for an AP, provided the client is stable and there are no specific concerns that require a nurse’s assessment.

C. Measuring vital signs: While measuring vital signs is a critical task, it can be delegated to an AP. The AP can be trained to accurately measure and report vital signs. However, the nurse should review and interpret the results.

D. Removing the sternal dressing: This is the correct answer. Removing a sternal dressing after cardiac surgery is a complex task that requires a nurse’s expertise2. The nurse needs to assess the surgical site for signs of infection or complications, which is beyond the scope of practice for an AP. Therefore, this task should not be delegated and should be performed by the nurse herself

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Correct Answer is C

Explanation

A. “They’ll protect your legs and heels from skin breakdown.”: While antiembolism stockings can provide some degree of protection against skin breakdown due to their snug fit, this is not their primary purpose. Their main function is to improve circulation and prevent blood clots, not to protect the skin.

B. “They’ll make it easier for you to do leg exercises after your surgery.”: Antiembolism stockings do not directly facilitate leg exercises. While they can help improve circulation which might indirectly aid in recovery, their primary purpose is to prevent the formation of blood clots in the lower extremities.

C. “They’ll improve your circulation to keep blood from pooling in your legs.”: This is correct. Antiembolism stockings, also known as compression stockings, are designed to apply pressure to your lower legs, helping to maintain blood flow and reduce discomfort and swelling. They can help prevent deep vein thrombosis (DVT), a type of blood clot that’s most common in the deep veins of your legs.

D. “They’ll help keep you warm immediately after your surgery.”: While antiembolism stockings might provide some warmth due to their material, this is not their primary function. Their main purpose is to improve circulation in the legs and prevent blood clots.

A. Ice cream B. Hot tea C. Orange ice pop D. Cranberry juice E. None F. None

Correct Answer is C

Explanation

Answer: C. Orange ice pop

Rationale:

A) Ice cream: Although cold, ice cream can be thick and may stick to the throat, potentially causing discomfort and an urge to clear the throat, which could disrupt the healing tissue and increase bleeding risk.

B) Hot tea: Hot beverages can irritate the surgical site and increase the risk of bleeding due to the heat dilating blood vessels in the area. Cold or room temperature items are recommended post-tonsillectomy.

C) Orange ice pop: An orange ice pop is cold and soothing, which can reduce swelling and pain. Its smooth texture is easy on the throat and unlikely to cause irritation, making it an ideal snack post-tonsillectomy.

D) Cranberry juice: Cranberry juice is acidic and can irritate the throat, causing discomfort and possibly increasing inflammation at the surgical site. Non-acidic, cold foods are preferable to aid in comfort and healing.

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A nurse is delegating tasks for an assistive personnel (AP) to perform for a client who is 1-day postoperative following cardiac surgery. Which of the following tasks should the nurse perform herself?

Nursing Test Bank

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