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
The correct answer is choice C. Allergy to gelatin is a contraindication for the inactivated influenza vaccine because gelatin is one of the ingredients in the vaccine. People with severe, life-threatening allergies to any ingredient in a flu vaccine (other than egg proteins) should not get that vaccine.
Choice A is wrong because pregnancy is not a contraindication for the inactivated influenza vaccine. In fact, pregnant people are recommended to get a flu shot because they are at higher risk of developing serious flu complications.
Choice B is wrong because immunosuppression is not a contraindication for the inactivated influenza vaccine. People with weakened immune systems can get a flu shot, but they should avoid the nasal spray flu vaccine which contains live viruses.
Choice D is wrong because moderate illness with fever is not a contraindication for the inactivated influenza vaccine. People who are moderately ill can still get a flu shot, but they should wait until they recover if they have a severe illness.
Correct Answer is A
Explanation
This instruction helps the client to establish a baseline of their bladder function and identify their voiding patterns. It also helps the nurse to design an individualized bladder-training program for the client.
Choice B is wrong because drinking 4 liters of fluid between 6:00 a.m. and 8:00 p.m. is excessive and can increase the frequency and urgency of urination. The client should drink enough fluids to prevent dehydration and constipation, but avoid drinking large amounts at one time or before bedtime.
Choice C is wrong because voiding every 2 hours while awake is not a bladder- training technique, but a scheduled toilet trip. Bladder training requires following a fixed voiding schedule and delaying urination after feeling the urge to go. Voiding every 2 hours may not allow the bladder to fill sufficiently and may interfere with the goal of increasing the bladder capacity.
Choice D is wrong because eliminating caffeine from the diet is not a specific instruction for bladder training, but a general lifestyle strategy to ease bladder problems. Caffeine can irritate the bladder and act as a diuretic, which can increase urine production and frequency.
However, eliminating caffeine alone may not be enough to improve urinary incontinence.
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