A nurse is making client assignments for the next shift. The nurse should assign which of the following clients to the assistive personnel?
A client who requires sterile dressing changes every three hours
A client who has a small bowel obstruction and requires insertion of a nasogastric tube
A client who is postoperative and requires intake and output measurement every 2 hr
A client on hospice who is unstable and requires frequent vital sign checks
The Correct Answer is C
A. A client who requires sterile dressing changes every three hours: Sterile dressing changes require skilled nursing care and must be performed by a licensed nurse. An assistive personnel (AP) is not trained or authorized to perform sterile procedures, making this assignment inappropriate.
B. A client who has a small bowel obstruction and requires insertion of a nasogastric tube: Inserting a nasogastric tube is an invasive procedure that requires clinical judgment and proper technique, which are responsibilities of licensed nursing staff, not assistive personnel.
C. A client who is postoperative and requires intake and output measurement every 2 hr: Measuring and recording intake and output is within the scope of practice for assistive personnel. It is a routine, noninvasive task that does not require nursing assessment or judgment.
D. A client on hospice who is unstable and requires frequent vital sign checks: An unstable hospice client requires close monitoring and clinical assessment. Although assistive personnel can measure vital signs, evaluating changes and determining their significance must be done by licensed nursing staff.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. "I will use animal skin condoms when having sex.": Animal skin condoms do not provide reliable protection against HIV transmission because they have small pores that can allow viruses to pass through. Latex or synthetic condoms are recommended for effective protection.
B. "I will put soiled dressings in a tied plastic bag before placing them in the trash.": Properly disposing of soiled dressings in a securely tied plastic bag helps prevent the spread of infectious material and minimizes the risk of exposure to others, reflecting good infection control practices at home.
C. "I will place used sharp items in an empty cereal box for disposal.": Sharps should be disposed of in a puncture-resistant, labeled sharps container. An empty cereal box is not puncture-proof and can easily be breached, posing a significant risk for needlestick injuries.
D. "I will disinfect contaminated hard surfaces with a mixture of one part peroxide to 10 parts water.": The correct disinfection solution for HIV is a mixture of one part bleach to 10 parts water, not peroxide. Using an incorrect disinfectant reduces the effectiveness of killing the virus on surfaces.
Correct Answer is D
Explanation
A. Changing a sterile dressing for a client who is postoperative: Changing a sterile dressing requires the use of sterile technique and nursing judgment, making it a task that must be performed by a licensed nurse, not delegated to assistive personnel.
B. Performing a gastrostomy feeding on a stable client: While assistive personnel can assist with feeding in general, administering a gastrostomy feeding requires specific assessment and verification of tube placement, which must be done by a licensed nurse.
C. Observing the patency of an intravenous catheter on a stable client: Observing and assessing IV catheter patency is a nursing responsibility. It requires assessment skills and cannot be delegated to assistive personnel.
D. Providing postmortem care to a client: Providing postmortem care, such as bathing, positioning, and preparing the body, is a task that can be safely delegated to assistive personnel, following proper facility protocols and respectful handling of the deceased.
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