A nurse is making client care assignments for an assistive personnel (AP). Which of the following tasks should the nurse assign to the AP?

Inspect the incision of a client who is postoperative following a leg amputation.

Evaluate the need to suction the airway of a client who has a new tracheostomy.

Complete postmortem care for a client who has died.

Feed a client who has difficulty swallowing liquids following a stroke.

Answer and Explanation

The Correct Answer is C

A. Inspect the incision of a client who is postoperative following a leg amputation is incorrect. Inspecting an incision requires clinical assessment to identify signs of infection, dehiscence, or other complications, which should be performed by a licensed nurse.

B. Evaluate the need to suction the airway of a client who has a new tracheostomy is incorrect. Suctioning the airway of a client with a tracheostomy is a skilled task that requires assessment of the airway and airway management, which should be performed by a nurse.

C. Complete postmortem care for a client who has died is correct. Postmortem care, such as cleaning and preparing the body, is a task that can be delegated to an AP. The AP should not be involved in clinical assessments but can perform routine care under supervision.

D. Feed a client who has difficulty swallowing liquids following a stroke is incorrect. Feeding a client with swallowing difficulties requires careful monitoring and risk assessment for aspiration, which is outside the scope of tasks that can be delegated to an AP without proper training.

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Correct Answer is B

Explanation

A. Reporting the incident to the charge nurse is incorrect as the first step. While this action may be necessary if the issue continues, the immediate step should be to intervene directly to stop the conversation and prevent further breach of confidentiality.

B. Telling the staff members to stop their discussion is correct. The nurse should immediately address the situation by asking the APs to stop discussing the client’s medical history in the hallway to protect client confidentiality. This is the most immediate and effective action in ensuring the client’s privacy is respected.

C. Participating in an in-service about client confidentiality is incorrect as the first step. While in-service education on client confidentiality is important, it is not an immediate action to address a current breach of confidentiality.

D. Speaking to the staff members in private about client confidentiality is incorrect. While private conversation is important to address the issue further, the first action is to stop the conversation immediately to prevent any further privacy violations.

A. Tell the client she should discuss this decision with her family. B. Discuss alternative treatment methods with the client. C. Ask the facility chaplain to visit the client. D. Support the client's decision to stop the treatment.

Correct Answer is D

Explanation

A. Tell the client she should discuss this decision with her family.: This is incorrect. While family involvement can be important in decisions regarding treatment, the nurse should respect the client's autonomy and support their right to make decisions about their own care.

B. Discuss alternative treatment methods with the client.: This is incorrect. Since the client has already made the decision to stop dialysis, the nurse should not push alternative treatment methods. The focus should be on supporting the client’s decision rather than presenting options they have chosen not to pursue.

C. Ask the facility chaplain to visit the client.: While a chaplain may provide valuable spiritual support, this is not the first action the nurse should take. It is more important to first support the client’s decision and ensure they are informed about the consequences.

D. Support the client's decision to stop the treatment.: This is correct. The nurse should support the client’s decision and provide care that aligns with the client’s values and wishes. It’s important to respect the client's right to make informed choices about their care, including the decision to discontinue dialysis.

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A nurse is making client care assignments for an assistive personnel (AP). Which of the following tasks should the nurse assign to the AP?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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