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 A

Explanation

A. Limiting the number of choices for the client is correct. Clients with Alzheimer's disease can become overwhelmed by too many options. Offering simple choices, such as "Would you like tea or juice?" instead of an open-ended question, helps reduce confusion and frustration.

B. Using written signs to assist with locating the bathroom is incorrect. While cues can be helpful, clients with Alzheimer's disease often experience difficulty processing written information as the disease progresses. Using pictures or symbols instead of words is more effective.

C. Providing a stimulating environment for the client is incorrect. An overly stimulating environment can increase agitation and confusion. A calm, structured setting with minimal distractions is better for clients with Alzheimer's disease.

D. Using confrontation to manage the client’s behavior is incorrect. Confronting or arguing with a client who has Alzheimer's disease can lead to increased agitation and distress. Instead, caregivers should use redirection and reassurance to manage behaviors effectively.

A. Insertion of a nasogastric tube B. Administration of an iron injection using Z-track technique C. Irrigation of a wound with antibiotic solution D. Placement of a central venous catheter

Correct Answer is D

Explanation

A. Insertion of a nasogastric tube: While informed consent is important for many procedures, the insertion of a nasogastric (NG) tube is generally considered a routine procedure that may not require formal informed consent unless specific complications or risks are involved.

B. Administration of an iron injection using Z-track technique: Informed consent is typically required for procedures with inherent risks or invasive elements, but routine administration of iron injections is not typically classified as needing informed consent, unless there are specific concerns.

C. Irrigation of a wound with antibiotic solution: Irrigation of a wound is typically a low-risk procedure, and although it is important to inform the client about the treatment, it generally does not require formal informed consent unless there are complications or risks involved.

D. Placement of a central venous catheter: Informed consent is required for the placement of a central venous catheter, as it is an invasive procedure with potential risks such as infection, bleeding, and damage to blood vessels. This procedure requires the nurse to obtain and document the client's consent before proceeding.

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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?

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