A nurse is planning assignments for the upcoming shift.
Which of the following tasks should the nurse delegate to an assistive personnel?

Obtain a client's vital signs every 4 hours.

Record a client's intake after each meal.

Transfer a client to physical therapy.

Insert an NG tube for a client who requires enteral feedings.

Answer and Explanation

Correct Answer : A,B,C

Choice A rationale

Obtaining a client's vital signs is a routine, non-invasive procedure that can be safely delegated to an assistive personnel (AP). The AP is trained to measure and record objective data such as temperature, pulse, respiration, and blood pressure. The nurse is responsible for interpreting the data and assessing for any abnormal findings, but the data collection itself falls within the scope of practice for an AP. This allows the nurse to focus on more complex tasks.

Choice B rationale

Recording a client's intake after each meal is a task focused on data collection and falls within the scope of practice for an assistive personnel (AP). The AP can accurately measure and document the quantity of food and fluids consumed by the client. The nurse is then responsible for analyzing this data to monitor the client's nutritional status and fluid balance, and to identify any potential complications, such as dehydration or malnutrition. This is a routine, non-complex task.

Choice C rationale

Transferring a client is a routine activity of daily living that an assistive personnel (AP) is trained to perform. It involves moving a client safely from one location to another, such as from the bed to a chair or to physical therapy. The AP is taught proper body mechanics and client transfer techniques to prevent injury to both the client and themselves. The nurse would provide supervision and assess the client's mobility status before the transfer.

Choice D rationale

Inserting an NG tube is an invasive procedure that requires advanced knowledge of anatomy, physiology, and sterile technique. It carries a risk of complications, such as aspiration or incorrect tube placement. Therefore, this task is outside the scope of practice for an assistive personnel and must be performed by a licensed nurse or other qualified healthcare professional. The nurse is responsible for confirming tube placement and monitoring for adverse effects.

Choice E rationale

Instructing a client on the use of an incentive spirometer involves client education, which is a key component of the nursing process. The nurse must assess the client's learning needs, provide accurate and safe instructions, and evaluate the client's understanding and ability to perform the technique correctly. This cognitive and educational task requires the critical thinking skills of a licensed nurse and cannot be delegated to an assistive personnel. *.

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Correct Answer is A

Explanation

Choice A rationale

Severe preeclampsia is characterized by high blood pressure, often accompanied by seizures (eclampsia). The client is at high risk for seizures, which can cause falls and injury. Ensuring the side rails are up is a critical safety measure to protect the client from falling out of bed during a seizure episode. This precaution is part of seizure protocols and is essential for client safety in this high-risk condition.

Choice B rationale

Ambulation is contraindicated for clients with severe preeclampsia. They are at high risk for seizures and should be on strict bed rest to minimize physical activity and stress, which can elevate blood pressure and increase the risk of a seizure. Bed rest also helps to improve placental perfusion, which is often compromised in preeclampsia.

Choice C rationale

In a client with severe preeclampsia, fetal well-being is a major concern. The client should have continuous or frequent fetal monitoring, not just twice daily. The compromised placental perfusion can lead to fetal distress, and frequent monitoring, such as nonstress tests or biophysical profiles, is necessary to detect any signs of distress and intervene promptly.

Choice D rationale

A low-protein diet is not recommended for a client with severe preeclampsia. Preeclampsia often causes proteinuria, a loss of protein in the urine, which can lead to low serum albumin levels. A high-protein diet is often encouraged to replace the lost protein and maintain oncotic pressure, which helps to reduce edema.

A. Histrionic. B. Avoidant. C. Obsessive-compulsive. D. Borderline.

Correct Answer is B

Explanation

Choice A rationale

Histrionic personality disorder is characterized by a pervasive pattern of excessive emotionality and attention-seeking behavior. Individuals with this disorder often feel uncomfortable when not the center of attention and may use dramatic, theatrical, or seductive behaviors to attract others. They are not typically withdrawn or anxious in social settings.

Choice B rationale

Avoidant personality disorder is characterized by a pervasive pattern of social inhibition, feelings of inadequacy, and hypersensitivity to negative evaluation. The client's statements of becoming "extremely anxious in social gatherings" and never feeling "good enough" for coworkers are hallmark symptoms of this disorder. They actively avoid social situations to prevent rejection.

Choice C rationale

Obsessive-compulsive personality disorder is characterized by a preoccupation with orderliness, perfectionism, and mental and interpersonal control. Individuals with this disorder are often rigid and inflexible. They are not typically described as being socially anxious due to feelings of inadequacy, but rather due to a need for control.

Choice D rationale

Borderline personality disorder is characterized by a pervasive pattern of instability in interpersonal relationships, self-image, and emotions, and marked impulsivity. While individuals with this disorder may experience intense anxiety and fear of abandonment, their core features are related to instability, not a pervasive feeling of not being "good enough" in social settings. .

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A nurse is planning assignments for the upcoming shift. Which of the following tasks should the nurse delegate to an assistive personnel?

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Naxlex Comprehensive Predictor Exams

A nurse is planning care for a client who is at 32 weeks of gestation and has severe preeclampsia. Which of the following actions should the nurse plan to take?

Correct Answer is A

Explanation

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Correct Answer is B

Explanation

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A nurse is planning assignments for the upcoming shift.
Which of the following tasks should the nurse delegate to an assistive personnel?