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 D
Explanation
(A) Respiratory acidosis: Respiratory acidosis is characterized by a low pH (<7.35) and a high PaCO2 (>45 mm Hg). In this case, the client’s pH is high and PaCO2 is normal, which rules out respiratory acidosis.
(B) Respiratory alkalosis: Respiratory alkalosis is characterized by a high pH (>7.45) and a low PaCO2 (<35 mm Hg). Although the client’s pH is high, the PaCO2 is normal, which rules out respiratory alkalosis.
(C) Metabolic acidosis: Metabolic acidosis is characterized by a low pH (<7.35) and a low bicarbonate level (<22 mEq/L). The client’s pH and bicarbonate levels are both high, which rules out metabolic acidosis.
(D) Metabolic alkalosis: Metabolic alkalosis is characterized by a high pH (>7.45) and a high bicarbonate level (>26 mEq/L). The client’s pH is 7.6 and bicarbonate level is 32 mEq/L, both of which are higher than normal. This indicates metabolic alkalosis. Therefore, the nurse should identify that the client is experiencing metabolic alkalosis.
Correct Answer is ["2"]
Explanation
To find out how many aspirin tablets the nurse should administer, we can divide the prescribed dosage by the amount of aspirin per tablet:
Dosage m prescribed: 650 mg
Amount of aspirin per tablet: 325 mg/tablet
Number of tablets = Dosage prescribed / Amount of aspirin per tablet
Number of tablets = 650 mg / 325 mg/tablet = 2 (rounded to the nearest whole number)
Therefore, the nurse should administer 2 tablets.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.