A nurse is delegating tasks to a group of staff members. Which of the following tasks should the nurse assign to an assistive personnel?
Irrigate a client's incision.
Determine a client's pain level.
Insert a nasogastric tube.
Provide postmortem care.
The Correct Answer is D
A. Irrigate a client's incision: Wound irrigation is a sterile procedure that requires nursing judgment and skill to prevent infection and assess wound healing. This task should not be delegated to assistive personnel.
B. Determine a client's pain level: Assessing pain requires clinical judgment to interpret subjective and objective findings and evaluate the need for interventions. This responsibility remains with the licensed nurse.
C. Insert a nasogastric tube: Insertion of a nasogastric tube is an invasive procedure that requires nursing knowledge and technical skill to ensure proper placement and prevent complications. It is not within the scope of assistive personnel.
D. Provide postmortem care: Postmortem care is a noninvasive task that involves preparing the body, performing hygiene, and maintaining dignity. It falls within the scope of practice for assistive personnel and can be safely delegated.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Rationale:
A. "I allow myself 10 minutes to finish each client's dressing change.": Assigning a fixed time to every procedure may not be realistic, as dressing change complexity and patient needs can vary. Overly rigid timing can compromise quality of care and flexibility in prioritizing tasks.
B. "I try to be working on at least three tasks at once so I can finish on time.": Multitasking in nursing can lead to errors, incomplete documentation, and compromised patient safety. Prioritizing and completing tasks sequentially is more effective for accuracy and quality care.
C. "I do not document my interventions in the electronic medical records until the end of each shift.": Delayed documentation increases the risk of errors, omissions, and inaccurate reporting. Timely documentation is essential for continuity of care and legal accuracy.
D. "I perform stat and time-critical care as soon as I receive the provider's prescriptions.": Addressing urgent and time-sensitive tasks immediately ensures that critical needs are met without delay. This reflects appropriate prioritization and effective time management.
Correct Answer is C
Explanation
Rationale:
A. The client's lung sounds remain clear during the transfusion: Clear lung sounds indicate the absence of fluid overload or pulmonary complications, which is a safety indicator, but it does not reflect the effectiveness of the transfusion in improving oxygen-carrying capacity.
B. The client's blood pressure increases to 140/85 mm Hg following the transfusion: A sudden rise in blood pressure could indicate fluid overload or a transfusion reaction, not necessarily a positive response to the transfusion.
C. The client's hemoglobin level increases following the transfusion: An increase in hemoglobin indicates that the transfused red blood cells have effectively raised the client’s oxygen-carrying capacity, demonstrating a positive therapeutic response.
D. The client is afebrile during the transfusion: Remaining afebrile indicates the absence of a febrile transfusion reaction, which is a safety measure, but it does not show that the transfusion achieved its therapeutic goal.
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