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
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
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Answer: C. Respiratory acidosis
Rationale:
A) Metabolic acidosis: This occurs when there is an excess of acid in the body or a loss of bicarbonate, often due to conditions such as renal failure or severe diarrhea. In chronic bronchitis, the primary issue is related to respiratory function rather than metabolic disturbances.
B) Respiratory alkalosis: This condition results from hyperventilation, leading to excessive loss of carbon dioxide. It is unlikely in a client with chronic bronchitis, who typically experiences difficulty in exhaling fully rather than hyperventilating.
C) Respiratory acidosis: In chronic bronchitis, airflow obstruction and reduced gas exchange can lead to carbon dioxide retention, resulting in respiratory acidosis. Symptoms like dyspnea and increased work of breathing support this imbalance, as the body is unable to adequately expel carbon dioxide.
D) Metabolic alkalosis: This imbalance results from excessive bicarbonate or loss of hydrogen ions, often related to prolonged vomiting or diuretics. It is not characteristic of chronic bronchitis, where the primary concern is respiratory function rather than metabolic processes.
Correct Answer is D
Explanation
A. Abuse:
Abuse typically involves intentional harm or mistreatment of another person. In this scenario, the nurse's error was inadvertent, not intentional, so it does not constitute abuse.
B. Battery:
Battery involves intentional harmful or offensive contact with another person without their consent. The inadvertent medication error in this scenario does not involve intentional contact or harm, so it does not constitute battery.
C. Assault:
Assault involves intentionally threatening or causing fear of immediate harm or offensive contact with another person. The inadvertent medication error, while resulting in harm, was not intentional or intended to cause fear, so it does not constitute assault.
D. Malpractice:
Malpractice refers to professional negligence or failure to adhere to the standard of care expected in one's professional duties, resulting in harm to a patient. In this scenario, the nurse's inadvertent medication error constitutes malpractice because it involved a breach of the standard of care expected in medication administration, resulting in harm to the client.
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