A nurse is making assignments for staff on an inpatient unit. Which of the following tasks can a nurse legally delegate to assistive personnel?

Obtaining the initial assessment of assigned clients

Educating a client and family members on home care

Changing a nonsterile dressing

Interpreting a client's diagnostic laboratory results

Answer and Explanation

The Correct Answer is C

Rationale:
A. Obtaining the initial assessment of assigned clients: The initial assessment requires nursing judgment and clinical decision-making, which are within the scope of practice of a registered nurse only. It involves data interpretation and establishing a baseline for care, tasks that cannot be delegated to assistive personnel.

B. Educating a client and family members on home care: Client and family teaching requires specialized nursing knowledge to ensure understanding and accuracy. This task involves evaluating learning needs and reinforcing critical information, responsibilities that cannot be legally delegated to assistive personnel.

C. Changing a nonsterile dressing: Assistive personnel can safely perform nonsterile procedures such as changing a clean dressing under the supervision of a nurse. This task involves routine care that does not require nursing judgment, making it appropriate for delegation.

D. Interpreting a client's diagnostic laboratory results: Interpretation of laboratory data involves analysis, clinical reasoning, and the ability to make informed nursing decisions. These actions fall strictly within the nurse’s professional scope of practice and cannot be delegated to assistive personnel.

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Correct Answer is B

Explanation

Rationale:
A. Encourage the client to eat a large meal in the evening: Clients with myasthenia gravis experience progressive muscle weakness, especially later in the day. Eating large evening meals increases the risk of fatigue and aspiration because muscle strength is reduced after activity.

B. Recommend the client eat within 45 min of taking cholinesterase-inhibitor medication: Cholinesterase inhibitors, such as pyridostigmine, enhance neuromuscular transmission and improve muscle strength. Eating within 45 minutes of taking the medication ensures optimal swallowing ability and reduces the risk of aspiration by aligning mealtime with peak effect.

C. Recommend the client extend their neck to facilitate swallowing: Extending the neck actually increases the risk of aspiration by opening the airway. Clients should be instructed to flex the neck slightly forward while swallowing to close the airway and promote safe swallowing mechanics.

D. Encourage the client to contact an occupational therapist to learn techniques of avoiding aspiration: While an occupational therapist can provide helpful adaptive techniques, primary aspiration prevention teaching should come directly from the nurse and speech-language pathologist.

A. The client started working in a parking garage 3 months ago. B. The client is doing 30 min of moderate exercise daily. C. The client is drinking 2.5 L of water per day. D. The client last visited the dentist 4 months ago

Correct Answer is A

Explanation

Rationale:
A. The client started working in a parking garage 3 months ago: Working in a parking garage may expose the client to exhaust fumes and carbon monoxide, which are hazardous during pregnancy. This environment increases the risk of fetal hypoxia and warrants further evaluation for occupational safety and potential exposure mitigation.

B. The client is doing 30 min of moderate exercise daily: Moderate exercise during pregnancy is generally safe and encouraged to promote maternal health, improve circulation, and reduce gestational complications. This activity does not indicate unsafe behavior.

C. The client is drinking 2.5 L of water per day: Adequate hydration is recommended during pregnancy to support maternal and fetal circulation, amniotic fluid levels, and overall health. Drinking 2.5 L per day is appropriate and does not require intervention.

D. The client last visited the dentist 4 months ago: Regular dental care is encouraged, but a visit every 4–6 months is generally considered safe and routine. This finding does not indicate unsafe behavior requiring urgent evaluation.

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A nurse is making assignments for staff on an inpatient unit. Which of the following tasks can a nurse legally delegate to assistive personnel?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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