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:
Watery stool is not indicative of paralytic ileus. Paralytic ileus is a condition characterized by the inhibition of bowel peristalsis, leading to symptoms such as abdominal distention, constipation, and lack of bowel sounds.
Choice B rationale:
Dizziness is not a specific symptom of paralytic ileus. Dizziness can be caused by various factors and is not directly related to the gastrointestinal condition.
Choice C rationale:
Abdominal distention is the correct choice. Paralytic ileus often presents with abdominal distention due to the accumulation of gas and fluids in the intestines. This distention can cause discomfort and a visible increase in the size of the abdomen.
Choice D rationale:
Oliguria, a decreased urine output, is not a typical symptom of paralytic ileus. It is more indicative of kidney-related issues or dehydration rather than gastrointestinal problems.
Correct Answer is D
Explanation
A. Incorrect. Documentation of sensitive material might have designated personnel, but this information does not need to be limited to the charge nurse.
B. Incorrect. Access to medical records should be limited to those with a need for that information, not every nurse in the facility.
C. Incorrect. Most facilities require more frequent password changes (e.g., every 90 days) to enhance security. Therefore, this statement may be inaccurate depending on the facility's policy.
D. Correct. Firewalls are security systems that are used to protect computer networks from unauthorized access. They are an important component of any computerized documentation system.
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