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 B
Explanation
A. Shaking insulin vials can cause bubbles and denature the insulin, especially NPH, which should be gently rolled between the hands to mix. Vigorous shaking can reduce effectiveness and increase the risk of inaccurate dosing.
B. Once regular and NPH insulin are drawn into the same syringe, the mixture should be administered promptly, ideally within 5 minutes, to maintain potency and prevent clumping. Delays can alter absorption and efficacy of the insulin.
C. The correct technique is to withdraw regular insulin first and then NPH, not the other way around. Drawing NPH first could contaminate the regular insulin vial with NPH, affecting rapid-acting insulin activity.
D. Air should be injected into each vial to equalize pressure before withdrawing the insulin, but the sequence should be air into NPH first, then air into regular insulin, to avoid contamination. Incorrect sequencing can introduce NPH into the regular insulin vial.
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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