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 B
Explanation
This statement indicates that the client has orthopnea, which is a sign of worsening heart failure and fluid overload. The nurse should intervene by assessing the client’s vital signs, oxygen saturation, lung sounds, and edema, and notifying the provider for possible diuretic adjustment.
Choice A is wrong because “I’m urinating in larger amounts.” is an expected outcome of taking furosemide, which is a loop diuretic that increases urine output and reduces fluid retention.
Choice C is wrong because “I suck on hard candy for my dry mouth.” is a harmless way to cope with the side effect of dry mouth caused by furosemide.
Choice D is wrong because “I’ve lost 3 pounds in the last week.” is a positive sign that the client is losing excess fluid and improving their heart failure
condition. A weight loss of 2 to 4 pounds per week is acceptable for clients taking diuretics.
Normal ranges for heart failure clients are:
- Blood pressure: less than 140/90 mmHg
- Heart rate: 60 to 100 beats per minute
- Respiratory rate: 12 to 20 breaths per minute
- Oxygen saturation: greater than 95%
- Weight: stable or decreasing within 2 to 4 pounds per week
Correct Answer is C
Explanation
Blood glucose 130 mg/dL.
This is because the normal range of blood glucose for pregnant women is 70 - 110 mg/dL .
A blood glucose level of 130 mg/dL indicates gestational diabetes, which can have adverse effects on the mother and the fetus.
The nurse should report this finding to the provider and initiate interventions such as dietary counseling, glucose monitoring, and insulin therapy if needed.
Choice A is wrong because WBC 7,000/mm³ is within the normal range for pregnant women, which is 4,500 to 10,000 cells/mcL .
A low WBC count would indicate an increased risk of infection, while a high WBC count would indicate inflammation or infection.
Choice B is wrong because hemoglobin 13 g/dL is within the normal range for pregnant women, which is 11 to 14 g/dL .
A low hemoglobin level would indicate anemia, while a high hemoglobin level would indicate dehydration or polycythemia.
Choice D is wrong because RBC 5.8 million/mm³ is within the normal range for pregnant women, which is 4.2 to 5.9 million/mm³ .
A low RBC count would indicate anemia or hemorrhage, while a high RBC count would indicate dehydration or polycythemia.
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