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. Eating three large meals and two snacks per day is not advisable for GERD patients. Large meals can increase the pressure on the lower esophageal sphincter (LES), leading to acid reflux. It is better to recommend smaller, more frequent meals to reduce symptoms.

B. Elevating the head of the bed while sleeping is correct. Elevating the head of the bed (usually by 6 to 8 inches) helps prevent acid from refluxing into the esophagus during sleep, a key management strategy for GERD.

C. Laying down for 1 hour following a meal is incorrect. After eating, patients with GERD should avoid lying down for at least 2 to 3 hours to prevent acid reflux. Lying down too soon after eating increases the risk of reflux.

D. Drinking 2 cups of coffee per day is not ideal for people with GERD, as caffeine can relax the LES, leading to increased reflux. While the exact amount varies by individual tolerance, it is generally recommended to limit or avoid caffeine.

A. Encourage the client to soak in a hot bath. B. Instruct the client to change positions frequently. C. Apply fundal pressure during contractions. D. Tell the client to push during contractions.

Correct Answer is B

Explanation

A. Encourage the client to soak in a hot bath.: While a warm bath can help alleviate muscle tension and discomfort, it is not recommended during the latent phase of labor due to the potential for increasing the risk of infection, especially if the membranes are ruptured.

B. Instruct the client to change positions frequently.: Frequent position changes during the latent stage of labor can help alleviate pelvic pain, improve comfort, and encourage progress in labor. This is a beneficial intervention that promotes movement and comfort without introducing unnecessary risks.

C. Apply fundal pressure during contractions.: Fundal pressure is not appropriate during the latent stage of labor, as it can cause fetal distress or other complications. It is typically avoided unless indicated in more advanced stages of labor under specific circumstances.

D. Tell the client to push during contractions.: Pushing is not recommended during the latent stage of labor. The latent phase involves the cervix gradually dilating, and pushing should be delayed until the active stage of labor when the cervix is fully dilated and ready for delivery.

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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 reinforcing teaching about disease management with a client who has GERD. Which of the following statements should the nurse make?

Correct Answer is B

Explanation

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Correct Answer is B

Explanation

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