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 A
Explanation
Choice A rationale
Flumazenil is a competitive antagonist for benzodiazepine receptors in the central nervous system. It works by blocking the effects of benzodiazepines, effectively reversing their sedative and anxiolytic effects. It is a specific antidote for benzodiazepine overdose and is indicated for the reversal of conscious sedation or for managing a benzodiazepine overdose. It should be used with caution due to the risk of seizures in long-term users.
Choice B rationale
Atropine is an anticholinergic medication primarily used to treat bradycardia (slow heart rate) and as an antidote for nerve agent or pesticide poisoning. It acts on muscarinic receptors to block the action of acetylcholine. It does not have any effect on benzodiazepine receptors and is therefore not the appropriate medication for treating benzodiazepine toxicity.
Choice C rationale
Activated charcoal is a general adsorbent used to treat certain oral poisonings and overdoses. It binds to the drug in the gastrointestinal tract, preventing its absorption into the bloodstream. It is only effective if administered early after ingestion of the drug. It is not a specific antidote for benzodiazepine toxicity, but a general measure to prevent absorption. Flumazenil is the specific antidote.
Choice D rationale
Naloxone is a narcotic antagonist that reverses the effects of opioid overdose by competing for the same receptor sites. It is specifically used for opioid toxicity and is ineffective for benzodiazepine overdose. Administering naloxone would not alter the effects of benzodiazepines and would be a completely inappropriate intervention for this type of toxicity.
Correct Answer is B
Explanation
Choice A rationale: Lubricating the catheter tip is an essential step to minimize trauma and discomfort during insertion. However, this is a technical preparation step that occurs after the sterile field has been established and the client has been draped.
Choice B rationale: Positioning the sterile drape is the priority action among the choices provided because it establishes the sterile field. Maintaining surgical asepsis is the most critical factor in preventing catheter-associated urinary tract infections (CAUTIs) during the procedure.
Choice C rationale: Cleansing the meatus with an antiseptic solution is the final step before actual insertion. This action must be performed after the sterile field is set up, the supplies are prepared, and the catheter is lubricated to ensure the area remains uncontaminated.
Choice D rationale: Attaching the prefilled syringe to the inflation hub is a preparation step to ensure the balloon can be inflated once the catheter is in the bladder. While important, it follows the establishment of the sterile environment.
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