A nurse is planning care for a client who is 1 day postoperative following abdominal surgery.
Which of the following tasks should the nurse delegate to an assistive personnel?
Transferring the client from the bed to a chair.
Checking the client’s surgical dressing for bleeding.
Determining whether the client has incisional pain.
Showing the client how to use an incentive spirometer.
The Correct Answer is A
Transferring the client from the bed to a chair. This is a task that can be delegated to an assistive personnel because it does not require nursing judgment or assessment. The nurse should provide clear instructions and supervise the assistive personnel during the transfer.
Choice B is wrong because checking the client’s surgical dressing for bleeding is a nursing assessment that requires clinical judgment and cannot be delegated.
The nurse should monitor the dressing for signs of infection, drainage, or dehiscence.
Choice C is wrong because determining whether the client has incisional pain is a nursing assessment that requires communication and evaluation skills and cannot be delegated.
The nurse should assess the client’s pain level, location, quality, and duration and administer pain medication as prescribed.
Choice D is wrong because showing the client how to use an incentive spirometer is a nursing intervention that requires teaching and evaluation skills and cannot be delegated.
The nurse should instruct the client on how to use the device to promote lung expansion and prevent atelectasis.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
This can be a sign of preeclampsia, a serious complication of pregnancy that causes high blood pressure and proteinuria.
The nurse should report this finding to the provider and monitor the client’s blood pressure, urine protein, and reflexes.
Choice A is wrong because leg cramps are a common discomfort during pregnancy and are not usually a sign of a complication.
Choice B is wrong because ptyalism, or excessive salivation, is a normal physiological change during pregnancy and does not indicate a problem.
Choice D is wrong because melasma, or darkening of the skin on the face, is also a normal physiological change during pregnancy and does not pose a risk to the mother or the fetus.
Correct Answer is B
Explanation
This is because the client has hypothyroidism, which means their thyroid gland does not produce enough thyroid hormone. Levothyroxine is a synthetic form of thyroid hormone that can replace the missing hormone and normalize the TSH level. The client’s TSH level is 8.9 mIU/L, which is above the normal range of 0.4 to 4.0 mIU/L. This indicates that the client’s current dosage of levothyroxine is insufficient and needs to be increased.
Choice A is wrong because thyroid ablation therapy is a treatment for hyperthyroidism, not hypothyroidism.
Thyroid ablation therapy involves destroying part or all of the thyroid gland with radioactive iodine or surgery, which reduces the production of thyroid hormone.
This would worsen the client’s condition and symptoms.
Choice C is wrong because lovastatin is a statin drug that lowers cholesterol levels. Hypothyroidism can cause high cholesterol levels, but this is usually corrected by levothyroxine therapy. Replacing lovastatin with cholestyramine, a bile acid sequestrant that also lowers cholesterol levels, would not address the underlying cause of hypothyroidism and would not improve the client’s TSH level.
Choice D is wrong because restricting the intake of iodized salt would not help the client with hypothyroidism. Iodine is an essential element for the synthesis of thyroid hormone, but most people in developed countries get enough iodine from their diet.
Hypothyroidism is usually caused by autoimmune disease, not iodine deficiency.
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