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.)
Transfer a client to physical therapy.
Obtain a client's vital signs every 4 hr.
Instruct a client on the use of an incentive spirometer.
Insert an NG tube for a client who requires enteral feedings.
Record a client's intake after each meal.
Correct Answer : A,B,E
Choice A rationale:
Transferring a client to physical therapy is a task that can be safely delegated to an assistive personnel (AP) as long as the client does not have any specific medical restrictions or requires specialized assistance during the transfer. APs are trained to assist with activities of daily living, including transferring clients from one place to another. However, it is essential for the nurse to assess the client's condition and provide clear instructions to the AP to ensure a safe transfer.
Choice B rationale:
Obtaining a client's vital signs every 4 hours is a routine task that can be delegated to an assistive personnel. APs are trained to measure vital signs such as blood pressure, heart rate, respiratory rate, and temperature under the supervision of licensed healthcare providers. Regular monitoring of vital signs is crucial in assessing the client's overall health status and detecting any changes that might require immediate medical attention.
Choice E rationale:
Recording a client's intake after each meal is a task that can be delegated to an assistive personnel. APs can document the amount and type of food and fluids consumed by the client. Monitoring the client's intake is important, especially if the client has specific dietary restrictions, allergies, or medical conditions that require close monitoring of their food and fluid intake.
Choice C rationale:
Instructing a client on the use of an incentive spirometer requires specialized knowledge and assessment of the client's respiratory status. This task should be performed by a licensed healthcare provider, such as a nurse or respiratory therapist, who can properly assess the client's lung function, demonstrate the correct technique, and ensure the client's safety during the process. Delegating this task to an AP could result in improper use of the spirometer, potentially leading to complications or ineffective therapy.
Choice D rationale:
Inserting an NG tube for a client who requires enteral feedings is a complex medical procedure that should be performed by a licensed nurse or healthcare provider with appropriate training and expertise. This procedure carries risks, including the risk of aspiration if not done correctly. Delegating this task to an AP is outside their scope of practice and could jeopardize the client's safety.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
Applying sterile gloves when changing the ostomy pouch is essential for infection control. However, this is a standard practice and not specific to the client's condition. While important, it is not the priority instruction for a client with a new ostomy.
Choice B rationale:
Notifying the provider if the stoma becomes pink and moist is crucial information for the client. A pink and moist stoma indicates good blood supply and healing, while changes in color or moisture might indicate complications. This instruction is essential for the client's ongoing care and to prevent potential complications, making choice B the correct answer.
Choice C rationale:
Emptying the ostomy pouch when it is half full is a general guideline to prevent leakage and maintain hygiene.
Choice D rationale:
Soaps with lotions or perfumes may interfere with the pouch seal or cause peristomal skin irritation. Rinse and dry well.
Correct Answer is C
Explanation
A. Bleeding gums are common during pregnancy due to hormonal changes that make gums more sensitive and prone to bleeding. This is not typically a sign of a serious condition and can usually be managed with good oral hygiene.
B. Faintness or lightheadedness upon rising is common in pregnancy due to blood pressure changes. This can often be managed with lifestyle modifications such as rising slowly, staying hydrated, and avoiding prolonged standing.
C. Swelling of the face during pregnancy can be an early sign of preeclampsia, a serious condition characterized by high blood pressure and organ damage. This is a concerning symptom that requires immediate evaluation by a healthcare provider.
D. Urinary frequency is a common and usually benign symptom during pregnancy, especially in the first and third trimesters due to hormonal changes and pressure on the bladder. It does not typically require urgent reporting unless accompanied by other symptoms such as pain or burning during urination, which could indicate a urinary tract infection.
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