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.
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 C
Explanation
Choice A rationale
A nonstress test (NST) does not require the client to fast. The client can eat and drink normally, and sometimes a sugary beverage is even encouraged to stimulate fetal movement, as the test aims to record fetal heart rate accelerations in response to these movements.
Choice B rationale
The nonstress test is a screening tool used to assess fetal well-being by measuring the fetal heart rate's response to fetal movement. It does not provide information about genetic problems, which are typically identified through genetic testing or prenatal diagnostic procedures such as amniocentesis.
Choice C rationale
A key component of the nonstress test involves the mother noting fetal movements. The client is given a marker, often a button, to press each time she feels the baby move. This action correlates the mother's perception of movement with the fetal heart rate accelerations recorded on the monitor.
Choice D rationale
Oxytocin is not administered during a nonstress test. The purpose of this test is to assess the baby's baseline heart rate and accelerations without external stimulation. Oxytocin is used in a contraction stress test, which is a different procedure to evaluate how the baby handles uterine contractions. *.
Correct Answer is A
Explanation
Choice A rationale
Based on the client's statements, there is strong evidence of neglect and potential exploitation. Neglect is indicated by the inadequate food supply and minimal meal preparation. Financial exploitation is suggested by the client's lack of access to their retirement income, despite it being used for their care. This situation poses a serious risk to the client's well-being, triggering the nurse's ethical and legal duty to report suspected elder abuse to the appropriate authorities.
Choice B rationale
While gathering more information is often a good practice, directly questioning the adult child about financial matters could escalate the situation and potentially put the client at further risk. The primary responsibility of the nurse in this scenario is to ensure the client's safety, and the existing information is sufficient to warrant a report. The client has already provided a detailed account of the financial arrangement and their lack of access to funds, which is a key indicator of exploitation.
Choice C rationale
Educating the adult child about nutrition, while potentially helpful in some circumstances, does not address the immediate and serious issues of neglect and financial exploitation. The client's safety is the priority. Focusing solely on education ignores the broader pattern of abuse and the client's vulnerability, which requires a more direct and protective intervention.
Choice D rationale
Encouraging the client to speak with their adult child may place them in a more vulnerable position and could increase the risk of retaliation or further neglect. The client has already expressed an understanding of their adult child's frustration, and this approach fails to address the power imbalance and exploitative nature of the relationship. It is not an appropriate or safe intervention in a situation of suspected abuse. *.
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