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.
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Related Questions
Correct Answer is {"dropdown-group-1":"D","dropdown-group-2":"E"}
Explanation
Rationale for Correct Choices:
- Intravenous antibiotic: The client is exhibiting signs of postpartum endometritis, including fever, tachycardia, a boggy and tender uterus, and foul-smelling lochia. IV antibiotics are the standard treatment to rapidly address bacterial infection and prevent systemic complications.
- Increase in daily fluid intake: Adequate hydration supports the client’s recovery by improving perfusion to the uterus, aiding in the clearance of infection, and preventing dehydration, especially if the client is febrile or breastfeeding.
Rationale for Incorrect Choices:
- Intrauterine tamponade balloon: This intervention is used primarily for severe postpartum hemorrhage, which is not evident in this client. Vital signs and lochia amount do not indicate ongoing hemorrhage.
- Kleihauer-Betke test: This test identifies fetal-maternal hemorrhage, which is not relevant to postpartum infection management. The client’s presentation suggests infection rather than blood loss.
- Tocolytic medication: Tocolytics are used to suppress preterm labor, which is not a concern for a postpartum client. The client’s symptoms are consistent with infection rather than uterine contractions needing suppression.
Correct Answer is C
Explanation
A. "Keep objects away from your center of gravity while lifting.": Lifting objects away from the body increases strain on the back and risks injury. Objects should be kept close to the body to reduce musculoskeletal stress.
B. "Keep your feet together to provide a tight base of support.": A narrow stance decreases stability and increases the risk of losing balance. Proper lifting requires a wide, stable base with feet shoulder-width apart.
C. "Tighten abdominal muscles to improve balance.": Engaging the core stabilizes the spine, maintains proper posture, and helps prevent back injuries during lifting. This is an important ergonomic technique.
D. "Bend at the waist when lifting objects from the floor.": Bending at the waist places excessive strain on the lower back. Proper lifting technique involves bending at the knees and hips while keeping the back straight.
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