A nurse is planning assignments for the upcoming shift. Which of the following tasks should the nurse delegate to an assistive personnel? (Select all that apply.)
Insert an NG tube for a client who requires enteral feedings.
Record a client's intake after each meal.
Obtain a client's vital signs every 4 hr.
Instruct a client on the use of an incentive spirometer.
Transfer a client to physical therapy.
Correct Answer : B,C,E
A. Insert an NG tube for a client who requires enteral feedings. This is incorrect because inserting an NG tube requires assessment and skill beyond the scope of practice of assistive personnel. This task should be performed by a nurse.
B. Record a client's intake after each meal. This is correct because recording intake is a non-clinical task within the scope of an assistive personnel’s role.
C. Obtain a client's vital signs every 4 hr. This is correct because measuring and documenting vital signs is a standard duty that assistive personnel can perform.
D. Instruct a client on the use of an incentive spirometer. This is incorrect because client education is a nursing responsibility and cannot be delegated to assistive personnel.
E. Transfer a client to physical therapy. This is correct because assistive personnel can safely assist with client transfers as long as no clinical judgment is required.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Shake both insulin vials for 2 min before withdrawing the doses. Insulin vials should never be shaken, as this can create air bubbles and affect dosage accuracy. NPH insulin should be gently rolled between the hands to mix.
B. Administer the mixture within 5 min of preparing it. While insulin should be administered promptly, there is no strict 5-minute requirement.
C. Withdraw the NPH insulin before the regular insulin. Regular insulin should be drawn up first to prevent contamination with the cloudy NPH insulin.
D. Inject air into the regular insulin vial before injecting air into the NPH vial. Air should be injected into the regular insulin first, then into the NPH insulin vial, before withdrawing the doses in the correct order.
Correct Answer is ["A","B","C","D","E"]
Explanation
- Heart rate decreased from 104/min to 88/min, indicating improved hemodynamic stability.
- Respiratory rate decreased from 20/min to 16/min, suggesting relaxation and reduced distress.
- Blood pressure slightly decreased from 132/84 mm Hg to 122/80 mm Hg, indicating improved comfort and reduced pain-related stress response.
- Pain level decreased to 3/10 after epidural placement, demonstrating effective pain management.
- FHR 150/min with moderate variability and accelerations present, no decelerations, indicating fetal well-being.
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