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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Sore throat. This is incorrect because a sore throat is an expected postoperative finding following a tonsillectomy and does not indicate a complication.
B. Dark brown emesis. This is incorrect because dark brown emesis may be swallowed blood from surgery and is not necessarily an immediate concern unless it continues or turns bright red.
C. Blood-tinged mucus. This is incorrect because small amounts of blood-tinged mucus are normal after a tonsillectomy and do not indicate active bleeding.
D. Frequent swallowing. This is correct because frequent swallowing can indicate active bleeding from the surgical site. Post-tonsillectomy hemorrhage is a serious complication that requires immediate intervention.
Correct Answer is E,C,D,A,B
Explanation
- Verify the clarity and color of the eye drops. Ensuring the medication is not expired or contaminated is the first step in safe administration.
- Tilt the client's head backward toward the ceiling. This position helps prevent the drops from draining out of the eye.
- Pull the client's lower lid down with the nondominant hand. This creates a small pocket for the eye drops to be instilled properly.
- Administer the prescribed number of drops. The medication should be placed in the conjunctival sac, not directly on the cornea.
- Apply gentle pressure to the client's punctum. This prevents systemic absorption by blocking the nasolacrimal duct and reduces systemic side effects.
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