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 D

Explanation

A. Positive clonus is a sign of hyperreflexia and can indicate worsening preeclampsia or severe central nervous system irritability. It is not a therapeutic effect of magnesium sulfate.

B. Urinary output 20 mL/hr is below the minimum expected urine output (which is generally 30 mL/hr). This finding suggests oliguria and may be a sign of worsening renal function, which is not a therapeutic effect of magnesium sulfate.

C. Respiratory rate 10/min is too low. Magnesium sulfate can cause respiratory depression, and a respiratory rate of 10/min may indicate toxicity. This is not a therapeutic effect.

D. Deep tendon reflexes 2+ is the correct answer. Magnesium sulfate is used to prevent seizures in preeclampsia by acting as a CNS depressant. A normal response of 2+ for deep tendon reflexes indicates that magnesium sulfate is having a therapeutic effect and the client is not experiencing magnesium toxicity (which would typically cause a decreased reflex response..

A. Bleach B. Isopropyl alcohol C. Chlorhexidine D. Hydrogen peroxide

Correct Answer is A

Explanation

A. Bleach: This is correct. Bleach (sodium hypochlorite. is recommended for disinfecting surfaces contaminated with blood or other body fluids due to its ability to effectively kill bloodborne pathogens, including HIV, which is crucial in a healthcare setting involving AIDS. The CDC recommends a solution of 1:10 dilution of bleach to water for blood spill clean-up.

B. Isopropyl alcohol: This is incorrect. While isopropyl alcohol can disinfect surfaces, it is not as effective as bleach in killing certain viruses, including HIV, in blood spills. It may not be sufficient for complete disinfection after a blood spill.

C. Chlorhexidine: This is incorrect. Chlorhexidine is an antiseptic commonly used for skin disinfection, not for cleaning contaminated surfaces. It is not recommended for disinfecting blood spills.

D. Hydrogen peroxide: This is incorrect. Hydrogen peroxide can be used for cleaning, but it is not as effective as bleach in eliminating certain pathogens like HIV after a blood spill. It also may not have the broad-spectrum disinfecting power needed for bloodborne pathogens.

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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

A nurse is collecting data from a client who is receiving magnesium sulfate via continuous IV infusion to treat preeclampsia. Which of the following findings indicates that the medication is having a therapeutic effect?

Correct Answer is D

Explanation

A nurse is caring for a client who has AIDS. Which of the following solutions should the nurse use to disinfect the client's overbed table following a blood spill?

Correct Answer is A

Explanation

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