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 {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"B"},"D":{"answers":"A"}}
Explanation
Rationale:
- Polyhydramnios: Excess amniotic fluid can overdistend the uterus, reducing its ability to contract effectively after delivery, which increases the risk of uterine atony and postpartum hemorrhage.
- Prolonged rupture of membranes: A long duration of ruptured membranes increases the risk of bacteria ascending into the uterus, which can lead to endometritis and systemic infection postpartum.
- Prenatal anemia: Low hemoglobin levels reduce oxygen delivery to tissues and impair the immune response, increasing susceptibility to infections such as endometritis or wound infection after cesarean birth.
- High parity: Multiple pregnancies can cause stretching and weakening of the uterine muscle, which may result in inadequate contraction postpartum, predisposing the client to uterine atony.
Correct Answer is C
Explanation
A. Remind the client to eat scheduled meals daily: Clients nearing the end of life often have a decreased appetite and may be unable or unwilling to eat. Forcing meals can cause discomfort and is not a priority at this stage.
B. Place the client in a supine position: Lying flat can increase the risk of aspiration and respiratory discomfort. Positioning the client for comfort, often semi-Fowler’s or side-lying, is preferred.
C. Offer the client a blanket to keep warm: Clients near the end of life may experience chills or cool extremities due to decreased circulation. Providing a blanket helps maintain comfort and dignity, which is a primary goal of end-of-life care.
D. Speak in a loud tone when addressing the client: Speaking loudly is unnecessary unless the client has hearing impairment. Communication should remain calm, gentle, and respectful to provide reassurance and maintain comfort.
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