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.

Answer and Explanation

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.

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Correct Answer is C

Explanation

A.Jogging or any form of vigorous exercise, especially high-impact activities, should generally be avoided for at least 4–6 weeks after retinal surgery. This is because high-impact activities can increase intraocular pressure and potentially disrupt the healing retina. Jogging involves bouncing or jolting movements, which could adversely affect the repair.

B. Bending at the waist places increased pressure on the eye and can disrupt the healing process after retinal surgery. This action increases intraocular pressure and is typically discouraged postoperatively.

C. Light lifting, such as lifting objects under 10 pounds, is typically allowed after several weeks of recovery, once the initial healing has occurred and the client is no longer at risk for increasing intraocular pressure or straining the surgical site.

D. While sewing itself is a low-impact activity, the act of sewing typically involves bending over or placing the head below the waist, which could still increase intraocular pressure. Early postoperative instructions often caution against activities that involve bending or straining the eyes, such as sewing, reading, or watching TV for extended periods.

D. Correct. After surgical repair of a detached retina, clients should avoid activities that might increase intraocular pressure, like heavy lifting or bending at the waist. Activities that do not strain the eye, like sewing, can typically be resumed earlier.

A. Hold the client's eyes shut for a few seconds. B. Cross the client's arms across their chest. C. Remove the client's dentures from their mouth. D. Place the client in a high-Fowler's position.

Correct Answer is A

Explanation

A. Correct. Holding the client's eyes shut for a few seconds after death helps keep the eyelids closed and gives a more peaceful appearance.
B. Incorrect. Crossing the client's arms across their chest is not typically part of postmortem care and may not be culturally appropriate in some cases.
C. Incorrect. Removing dentures from the mouth is not a standard step in postmortem care unless specifically requested by the family or if they pose a risk of aspiration.
D. Incorrect. Placing the client in a high-Fowler's position is not necessary after death and is not part of postmortem care.

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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.)

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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.)