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 A
Explanation
A. Correct. Administering a cathartic suppository can help stimulate bowel movement and facilitate a bowel-training program, particularly for individuals with altered bowel function due to spinal cord injury.
B. Incorrect. Adequate fluid intake is important, but limiting fluid intake is not typically recommended for clients with spinal cord injuries.
C. Incorrect. Refined grains are not specifically indicated for promoting bowel function. A balanced diet with sufficient fiber is more appropriate.
D. Incorrect. Providing a cold drink prior to defecation might not have a significant impact on bowel function and is not a commonly recommended intervention.
Correct Answer is ["B","D","E"]
Explanation
The nurse should discuss the following dietary recommendations with the client who has Crohn's disease:
Avoid eating fried, fatty foods and large meals: Fried and fatty foods can be difficult to digest and may worsen symptoms of diarrhea and abdominal pain. Consuming large meals can also put additional strain on the digestive system.
Limit high fiber foods, such as beans, popcorn, and seeds: High fiber foods can be challenging to digest and may exacerbate symptoms of Crohn's disease. Limiting these foods can help reduce gastrointestinal irritation and promote symptom relief.
Take a vitamin supplement daily with a meal: Crohn's disease can lead to nutrient deficiencies due to malabsorption. Taking a daily vitamin supplement with a meal can help ensure that the client receives essential nutrients and maintain overall nutritional status.
The following options are not appropriate dietary recommendations for a client with Crohn's disease:
- Drinking dairy and effervescent sodas for hydration: Dairy products can trigger symptoms in some individuals with Crohn's disease, especially if they have lactose intolerance. Effervescent sodas may contain carbonation and artificial sweeteners that can aggravate symptoms. Encouraging non-dairy sources of hydration, such as water or herbal teas, would be more appropriate.
- Enjoying fast food restaurants only if dining with friends: Fast food options are generally high in fat, sodium, and other additives that may worsen symptoms in individuals with Crohn's disease. It is advisable to limit or avoid fast food consumption altogether, regardless of whether dining alone or with others.
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