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.
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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Contacting the provider within 48 hr is incorrect. A prescription for restraints must be obtained within 1 hour of applying restraints, not within 48 hours. The nurse should ensure that this prescription is obtained promptly.
B. Removing the restraints every 2 hr is correct. The nurse should remove the restraints every 2 hours to assess the skin, provide range-of-motion exercises, and offer comfort. This ensures that the client is not harmed from prolonged restraint use.
C. Checking that one finger fits between the client's wrists and the restraints is incorrect. The nurse should ensure that the restraints are snug but not too tight to cause injury, typically allowing for two fingers of space, not just one.
D. Fastening the restraints' ties to the bed's side rails is incorrect. Restraints should be fastened to a movable part of the bed frame (not side rails) to prevent injury or accidental strangulation. The side rails can move and cause undue tension on the restraints.
Correct Answer is B
Explanation
A. “This medication will darken the color of my eyes.” is incorrect. Timolol is a nonselective beta-blocker used to reduce intraocular pressure in glaucoma. It does not typically cause eye color changes.
B. "I should check my heart rate while taking this medication." is correct. Timolol can cause systemic side effects such as bradycardia, so the client should monitor their heart rate while taking the medication.
C. "I should take a zinc supplement while taking this medication." is incorrect. Zinc supplementation is not related to the use of timolol.
D. “This medication will dilate my eyes." is incorrect. Timolol works by decreasing aqueous humor production, reducing intraocular pressure, and does not cause dilation of the eyes. Medications like atropine are used for pupil dilation.
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