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
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Quantitative research involves the collection and analysis of numerical data to answer research questions and test hypotheses. Statistical methods are used to analyze the data and draw conclusions about relationships, differences, or effects.
A. "Quantitative research aims to understand the feelings associated with a particular event":
This statement is incorrect. Quantitative research focuses on measurable data and is concerned with objective observations rather than subjective feelings or experiences.
B. "Qualitative research studies how to implement EBP into various settings":
This statement is incorrect. Qualitative research explores subjective experiences, perceptions, and meanings to gain a deeper understanding of phenomena. It is not specifically focused on implementing evidence-based practice (EBP) into various settings.
D. "Qualitative research uses larger sample sizes than quantitative research":
This statement is incorrect. Qualitative research typically involves smaller sample sizes compared to quantitative research. The emphasis in qualitative research is on depth and richness of data rather than statistical generalizability.
Correct Answer is C
Explanation
Respiratory acidosis occurs when there is inadequate removal of carbon dioxide (PaCO2) by the lungs, leading to an increase in the partial pressure of carbon dioxide (hypercapnia) and a decrease in pH.
In this case, the pH is low (7.22), and the PaCO2 is elevated (68 mm Hg), indicating respiratory acidosis. The pH is below the normal range, suggesting acidemia.
The other ABG values (PaO2, oxygen saturation, and bicarbonate) are within or close to normal limits, which do not support the diagnosis of metabolic acidosis, respiratory alkalosis, or metabolic alkalosis.
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