A nurse is delegating tasks to the assistive personnel (AP). The nurse should direct the AP to complete which of the following tasks first?

Deliver a clean voided urine specimen to the laboratory.

Feed a client who has bilateral casts due to upper arm fractures.

Perform blood glucose monitoring of a client who has a prescription for short-acting insulin prior to breakfast.

Obtain an extra box of tissues for a client who is concerned about running out of them.

Answer and Explanation

The Correct Answer is C

Choice A reason: Delivering a urine specimen to the laboratory is not a priority task, as it does not affect the client's immediate health or safety. This task can be done later or delegated to another staff member.

Choice B reason: Feeding a client who has bilateral casts is an important task, as it helps the client meet their nutritional needs and prevents complications such as pressure ulcers. However, this task is not as urgent as monitoring blood glucose levels, as it can be done within a reasonable time frame without causing harm to the client.

Choice C reason: Performing blood glucose monitoring of a client who has a prescription for short-acting insulin is a priority task, as it determines the dosage of insulin that the client needs to receive. Insulin is a high-alert medication that can cause serious adverse effects if given incorrectly. Therefore, this task should be done first by the AP who has been trained and certified to do so.

Choice D reason: Obtaining an extra box of tissues for a client who is concerned about running out of them is a low-priority task, as it does not affect the client's physical or psychological well-being. This task can be done at any time or delegated to another staff member.

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Correct Answer is B

Explanation

Choice A reason: Performing carotid massage is not an appropriate action for a nurse to take when a client has signs of a stroke, as it may worsen the condition or cause complications. Carotid massage is a technique that involves applying pressure to the carotid artery in the neck to stimulate the vagus nerve and slow down the heart rate. It is used to treat some types of arrhythmias, such as supraventricular tachycardia. However, carotid massage may dislodge a blood clot or plaque from the carotid artery and cause an embolic stroke, which is a type of ischemic stroke that occurs when a blood clot travels to the brain and blocks a blood vessel. Carotid massage may also cause bradycardia, hypotension, or syncope, which can reduce the blood flow to the brain and worsen the ischemic damage.

Choice B reason: Calling for help is an appropriate action for a nurse to take when a client has signs of a stroke, as it initiates the emergency response and allows for prompt evaluation and treatment. Stroke is a medical emergency that occurs when the blood supply to a part of the brain is interrupted, causing brain cells to die. The sooner the stroke is recognized and treated, the better the chances of survival and recovery. Therefore, the nurse should call for help as soon as possible and activate the stroke protocol in the facility.

Choice C reason: Providing the client with water to test the gag reflex is not an appropriate action for a nurse to take when a client has signs of a stroke, as it may cause aspiration or choking. A gag reflex is an involuntary contraction of the throat muscles that prevents foreign objects from entering the airway. It is tested by touching the back of the throat with a tongue depressor or a cotton swab. However, this test is not indicated in a client who has signs of a stroke, as it may trigger vomiting or coughing, which can increase intracranial pressure or cause bleeding. Moreover, giving water to a client who has signs of a stroke may be dangerous, as they may have dysphagia (difficulty swallowing) or facial weakness, which can impair their ability to swallow safely and increase the risk of aspiration pneumonia.

Choice D reason: Administering thrombolytics is not an appropriate action for a nurse to take when a client has signs of a stroke, as it may be contraindicated or harmful depending on the type and timing of the stroke. Thrombolytics are medications that dissolve blood clots and restore blood flow. They are used to treat ischemic stroke, which is caused by a blood clot that blocks a blood vessel in the brain. However, thrombolytics are not effective for hemorrhagic stroke, which is caused by bleeding into or around the brain. In fact, thrombolytics may worsen hemorrhagic stroke by increasing bleeding and intracranial pressure. Therefore, thrombolytics should only be given after confirming the type of stroke by imaging tests such as computed tomography (CT) scan or magnetic resonance imaging (MRI). Thrombolytics should also be given within a specific time window after the onset of symptoms, usually within 3 to 4.5 hours, as they may lose their effectiveness or cause complications if given too late. Therefore, administering thrombolytics is not an action that a nurse can take without proper assessment and orders from the health care provider.

A. Black tag B. Red tag C. Green tag D. Yellow tag

Correct Answer is B

Explanation

Choice A reason: A black tag is not the appropriate priority tag for this client, as it indicates that the client is dead or has injuries that are incompatible with life. A black tag is used for clients who have no signs of life, such as pulse, respiration, or pupillary response, or who have severe injuries that cannot be treated with the available resources, such as massive head trauma, decapitation, or incineration. A black tag means that no further care or intervention is provided to the client.

Choice B reason: A red tag is the appropriate priority tag for this client, as it indicates that the client has life-threatening injuries that require immediate attention and treatment. A red tag is used for clients who have compromised airway, breathing, or circulation, such as respiratory distress, shock, severe bleeding, chest pain, or head injury. A red tag means that the client is given the highest priority and is treated as soon as possible.

Choice C reason: A green tag is not the appropriate priority tag for this client, as it indicates that the client has minor injuries that do not require urgent care or intervention. A green tag is used for clients who have stable vital signs and can walk or move without assistance, such as abrasions, sprains, fractures, or minor burns. A green tag means that the client is given the lowest priority and is treated after all other clients.

Choice D reason: A yellow tag is not the appropriate priority tag for this client, as it indicates that the client has serious injuries that require observation and treatment within a short time frame. A yellow tag is used for clients who have potential complications or deterioration of their condition, such as abdominal pain, pelvic injury, open wounds, or spinal injury. A yellow tag means that the client is given the second highest priority and is treated within 30 to 60 minutes.

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A nurse is delegating tasks to the assistive personnel (AP). The nurse should direct the AP to complete which of the following tasks first?

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