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
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.
Correct Answer is A
Explanation
Choice A rationale
Applying petroleum jelly to the glans of the penis is an important step in the care of a newborn who has undergone a Gomco circumcision. This acts as a protective barrier to prevent the glans from sticking to the diaper, which can cause pain and disrupt the healing process. This is done with each diaper change for the first few days.
Choice B rationale
The yellow, sticky exudate that forms on the glans is a normal part of the healing process and is composed of fibrin and serum. Wiping it off can disrupt the healing tissue and increase the risk of bleeding and infection. The parent should be instructed to allow this exudate to fall off naturally.
Choice C rationale
Applying gentle pressure with a diaper is not an appropriate intervention. The area should be kept as free from pressure as possible to promote healing and reduce discomfort. Pressure could cause bleeding, pain, or damage to the delicate new tissue that is forming.
Choice D rationale
Alcohol is a harsh astringent that can cause significant pain and irritation to the sensitive, healing tissue of the glans. It can also dry out the skin, delaying the healing process. Only warm water should be used to clean the area during diaper changes. .
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