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.

Answer and Explanation

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.

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Correct Answer is A

Explanation

A. Acute hemolytic:
Acute hemolytic transfusion reactions typically present with symptoms such as fever, chills, flank pain, hemoglobinuria (blood in the urine), and possibly hypotension. This occurs due to the rapid destruction of transfused red blood cells, often because of ABO incompatibility between the donor and recipient. The symptoms described in the scenario, including chest tightness, are not consistent with acute hemolytic reactions.

B. Allergic:
Allergic reactions to blood transfusions can manifest with symptoms such as itching, hives, flushing, and mild respiratory distress. While headache and low-back pain can occur in allergic reactions, the feeling of "tightness" in the chest is more indicative of another type of reaction.

C. Bacterial:
Bacterial contamination of blood products can lead to transfusion-related sepsis. Symptoms may include fever, chills, hypotension, and rapid onset of shock. However, the presence of headache and low-back pain, along with chest tightness, is not typically associated with bacterial contamination.

D. Febrile nonhemolytic:
Febrile nonhemolytic transfusion reactions are characterized by fever, chills, and rigors. While fever and chills are common symptoms, they do not typically cause chest tightness or low-back pain.

A. Activate the fire alarm system. B. Evacuate clients from the area. C. Obtain and use a fire extinguisher. D. Close the doors and windows on the unit.

Correct Answer is B

Explanation

Answer: B

Rationale:

A) Activate the fire alarm system:

While activating the fire alarm system is essential in alerting everyone to the fire, the immediate safety of the clients must be prioritized first. Ensuring clients are safe from potential harm should precede alerting others.

B) Evacuate clients from the area:

Evacuating clients from the area is the first priority as it directly ensures their safety. In the event of a fire, removing individuals from the source of danger is crucial to prevent injury or harm.

C) Obtain and use a fire extinguisher:

Using a fire extinguisher to put out the fire is important, but it should not be the first action. Ensuring clients are evacuated to safety must take precedence before attempting to control the fire.

D) Close the doors and windows on the unit:

Closing doors and windows can help contain the fire and smoke, but this should follow the evacuation of clients. The primary concern is to get clients to a safe area first before taking measures to contain the fire.

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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.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is monitoring a client who is receiving a transfusion of packed RBCs. The client reports chills, headache, low-back pain, and a feeling of "tightness" in their chest. The nurse should identify that the client has developed which of the following types of transfusion reactions?

Correct Answer is A

Explanation

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Correct Answer is B

Explanation

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