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
“I will not play soccer until my doctor tells me I can.” This statement indicates that the client understands the risk of splenic rupture due to splenomegaly and the need to avoid contact sports until the spleen returns to normal size.
Choice A is wrong because antibiotics are not effective for infectious mononucleosis, which is caused by a virus.
Choice C is wrong because varicella booster is not related to infectious mononucleosis and there is no evidence that the client needs it.
Choice D is wrong because jaundice (yellowing of the eyes and skin) is not a common manifestation of infectious mononucleosis and may indicate another condition such as hepatitis.
Normal ranges for spleen size are 7 to 14 cm in length and 3 to 4 cm in thickness.
Correct Answer is B
Explanation
The indirect Coombs test is used to detect antibodies against foreign red blood cells in the maternal serum. This test can help identify maternal-fetal blood incompatibility, which can cause hemolytic disease of the newborn.
Choice A is wrong because homocysteine is a type of amino acid and is not related to blood compatibility.
Choice C is incorrect because erythropoietin is a hormone that regulates red blood cell production and is not a specific test for detecting maternal-fetal blood incompatibility.
Choice D is not the correct answer as aPTT (activated partial thromboplastin time) is a test used to evaluate blood clotting factors and is not directly related to monitoring maternal-fetal blood incompatibility.
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