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.)
Instruct a client on the use of an incentive spirometer.
Insert an NG tube for a client who requires enteral feedings.
Obtain a client's vital signs every 4 hr.
Record a client's intake after each meal,
Transfer a client to physical therapy.
Correct Answer : C,D,E
C. Obtain a client's vital signs every 4 hr:
This task can typically be delegated to assistive personnel (AP) who have been trained and deemed competent in measuring vital signs. Routine monitoring of vital signs, such as temperature, pulse, respirations, and blood pressure, is within the scope of practice for AP and does not require the specialized skills of a licensed nurse.
D. Record a client's intake after each meal:
Assistive personnel can be delegated the task of recording a client's intake after each meal. This involves documenting the amount and type of food and fluids consumed by the client. While assessment of intake may involve some judgment, AP can be trained to perform this task accurately and consistently.
E. Transfer a client to physical therapy:
Assistive personnel can assist with transferring clients to physical therapy sessions. This may include tasks such as assisting clients into a wheelchair or onto a stretcher and accompanying them to the therapy area. While ensuring client safety during transfers is crucial, AP can perform these tasks under the direction and supervision of licensed nursing staff or physical therapists.
A. Instruct a client on the use of an incentive spirometer:
Teaching clients how to use medical equipment, such as an incentive spirometer, typically requires specialized knowledge and skills that fall within the scope of practice of licensed nursing staff. Therefore, this task should not be delegated to assistive personnel.
B. Insert an NG tube for a client who requires enteral feedings:
Inserting an NG tube is a specialized nursing skill that requires training, expertise, and an understanding of anatomy, proper technique, and potential complications. This task should only be performed by licensed nursing staff, such as registered nurses (RNs) or licensed practical nurses (LPNs), who have received appropriate education and training.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. "I will take the medication in the morning." - Metformin extended-release tablets are typically taken with the evening meal to minimize gastrointestinal side effects. Taking it in the morning may increase the risk of side effects during the day.
B. "I will avoid crushing this medication." - Metformin extended-release tablets should not be crushed, chewed, or broken, as doing so can disrupt the extended-release mechanism, leading to an increased risk of adverse effects or decreased efficacy.
C. "I will take the medication on an empty stomach." - While metformin can be taken with or without food, it is generally recommended to take it with meals to reduce gastrointestinal side effects. Taking it on an empty stomach may increase the risk of nausea or upset stomach.
D. "I will expect to gain weight." - Weight loss is a common side effect of metformin, particularly in individuals with type 2 diabetes. Therefore, expecting weight gain would indicate a misunderstanding of the medication's effects.
Correct Answer is B
Explanation
A. The client's heart rate increases by 10/min: An increase in heart rate upon changing positions may occur as a compensatory mechanism to maintain blood pressure, but it is not indicative of orthostatic hypotension. Orthostatic hypotension is characterized by a decrease in blood pressure upon assuming an upright position.
B. The client's systolic blood pressure decreases by 25 mm Hg: Orthostatic hypotension is defined as a decrease in systolic blood pressure of 20 mm Hg or more, or a decrease in diastolic blood pressure of 10 mm Hg or more, within 3 minutes of standing up from a supine position. Therefore, a decrease in systolic blood pressure by 25 mm Hg upon changing positions is consistent with orthostatic hypotension.
C. The client's diastolic blood pressure increases by 10 mm Hg: Orthostatic hypotension typically involves a decrease in both systolic and diastolic blood pressure upon assuming an upright position. An increase in diastolic blood pressure is not consistent with orthostatic hypotension.
D. The client reports heart palpitations: Heart palpitations may occur due to various reasons, such as anxiety or cardiac arrhythmias, but they are not specific to orthostatic hypotension. While orthostatic hypotension may cause symptoms like dizziness or lightheadedness, heart palpitations are not typically associated with this condition.
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