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.
Instructing a client on the use of an incentive spirometer involves client education
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. *.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
An acute hemolytic transfusion reaction is a severe and life-threatening reaction caused by an incompatibility between the donor's blood and the client's blood. The recipient's antibodies attack and destroy the transfused red blood cells, leading to hemolysis. The classic symptoms include chills, fever, low-back pain, tightness in the chest, and headache. This reaction is a medical emergency requiring immediate cessation of the transfusion and supportive care.
Choice B rationale
An allergic reaction to a blood transfusion is typically caused by the recipient's antibodies reacting to a foreign plasma protein in the donor blood. Symptoms can range from mild, such as hives and itching, to severe, such as anaphylaxis. However, symptoms like low-back pain and a feeling of "tightness" in the chest are more characteristic of a hemolytic reaction rather than a simple allergic response.
Choice C rationale
A febrile nonhemolytic transfusion reaction is the most common type of transfusion reaction. It is caused by the recipient's antibodies reacting to donor white blood cells. Symptoms include fever and chills, but typically do not include the severe manifestations of low-back pain, headache, and chest tightness that are seen in a hemolytic reaction. The reaction is usually not life-threatening.
Choice D rationale
Transfusion-related acute lung injury (TRALI) is a serious and potentially fatal complication of a transfusion. It is characterized by the sudden onset of non-cardiogenic pulmonary edema within six hours of a transfusion. Symptoms primarily involve respiratory distress, such as dyspnea and hypoxemia. While TRALI is severe, the symptoms presented, particularly the low-back pain and chest tightness, are more indicative of an acute hemolytic reaction. .
Correct Answer is D
Explanation
Choice A rationale
Using clean technique for invasive procedures in a neutropenic client is insufficient. Neutropenia is a severe reduction in neutrophils, a key component of the immune system, leaving the client highly susceptible to infection. Aseptic or sterile technique, rather than clean technique, is necessary for all invasive procedures to prevent the introduction of pathogens. This includes strict hand hygiene, sterile gloves, and sterile fields to minimize infection risk.
Choice B rationale
Allowing healthy children to visit is a dangerous practice for a neutropenic client. Children, even those appearing healthy, can carry and transmit pathogens like viruses and bacteria that their developing immune systems can easily fight off. In a client with neutropenia, however, these common microorganisms can cause severe, life-threatening infections due to the lack of an adequate immune response. Therefore, visitors must be carefully screened.
Choice C rationale
Cleaning the client's room every 2 days is an inadequate frequency for a neutropenic client. An environment with reduced pathogen exposure is crucial for these immunocompromised clients. The room should be cleaned daily to minimize the accumulation of dust, dirt, and microorganisms. All surfaces, including floors, tables, and equipment, must be disinfected to reduce the risk of nosocomial infections and maintain a sterile environment.
Choice D rationale
Neutropenia impairs the body's ability to mount a fever response to infection. Therefore, a low-grade temperature elevation may be the only sign of a serious infection. Monitoring the client's temperature frequently, typically every 4 hours, is a critical nursing intervention. Early detection of a fever, even a slight one, allows for prompt initiation of antibiotics and other treatments, significantly improving the client's prognosis and preventing a potential septic shock. *.
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