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.

Answer and Explanation

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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Correct Answer is ["2.5"]

Explanation

Calculation:

Desired dose = 20 mg.

Available concentration = 40 mg / 5 mL

= 8 mg/mL.

Calculate the volume to administer in milliliters (mL).

Volume to administer (mL) = Desired dose (mg) / Available concentration (mg/mL)

= 20 mg / 8 mg/mL

= 2.5 mL.

A. Uterus firm at 1 cm above the umbilicus and tender to palpation. B. Moderate amount of dark brown, foul-smelling lochia noted C. Surgical incision well approximated with slight edema present D. Temperature 38.2° C (100.8° F) E. Respiratory rate 18/min F. SaO2 97% on room air G. WBC count 33,000/mm3

Correct Answer is ["A","B","D","G"]

Explanation

Rationale for Correct Answers:

Uterus firm at 1 cm above the umbilicus and tender to palpation: Normally, by postpartum day 3, the uterus should be well below the umbilicus. A uterus that is still above and tender suggests endometritis or subinvolution, especially when combined with foul-smelling lochia.
Moderate amount of dark brown, foul-smelling lochia noted: Lochia should progress from rubra (day 1–3, red) → serosa (day 4–10, pink/brown) → alba (day 10 onward, white/yellow). Foul-smelling lochia is a hallmark of uterine infection (endometritis).
Temperature 38.2° C (100.8° F): A postpartum fever ≥38°C on two occasions, or even once when associated with uterine tenderness and foul lochia, is significant and indicates infection.
WBC count 33,000/mm³: Although WBCs can be physiologically elevated postpartum (up to 20,000–25,000), a count this high is abnormal and strongly suggests severe infection.

Rationale for Incorrect Answers:

Surgical incision well approximated with slight edema present: Mild edema is expected in the early healing process; no erythema, drainage, or dehiscence is noted, so no immediate concern.
Respiratory rate 18/min: This is within normal range (12–20/min), no evidence of respiratory compromise.

SaO₂ 97% on room air: This is normal oxygen saturation, not concerning

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A nurse is delegating tasks to a group of staff members. Which of the following tasks should the nurse assign to an assistive personnel?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is ["2.5"]

Explanation

Correct Answer is ["A","B","D","G"]

Explanation

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