A nurse is planning care for clients.
Which of the following tasks can the nurse delegate to an assistive personnel (AP)?

Providing tracheostomy care for a client.

Assessing a client who just returned from surgery.

Teaching a client who is preoperative how to use an incentive spirometer.

Obtaining a blood pressure for a client who is to be discharged later in the day.

Answer and Explanation

The Correct Answer is D

The correct answer is Choice D: Obtaining a blood pressure for a client who is to be discharged later in the day.

Choice A rationale:

Providing tracheostomy care requires specialized training and assessment skills, which are beyond the scope of practice for assistive personnel (AP).

Choice B rationale:

Assessing a client who just returned from surgery involves clinical judgment and decision-making, which are responsibilities of a licensed nurse, not assistive personnel.

Choice C rationale:

Teaching a client how to use an incentive spirometer requires patient education skills and the ability to assess the client's understanding, which are tasks for a licensed nurse.

Choice D rationale:

Obtaining a blood pressure is a routine task that can be delegated to assistive personnel, as it does not require advanced clinical judgment or specialized training.

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Correct Answer is B

Explanation

Step 1: Identify the amount of lidocaine required, which is50 mg.

Step 2: Identify the concentration of available lidocaine, which is200 mg/mL.

Step 3: Calculate the volume of lidocaine to be administered using the formula:

Volume (mL) = Amount (mg) ÷ Concentration (mg/mL)

So, the calculation is:

Volume (mL) = 50 mg ÷ 200 mg/mL = 0.25 mL

Therefore, the nurse should administer0.25 mLof lidocaine per dose. This is the final answer and it is rounded off to the nearest hundredth as required.

A. Phlebitis. B. Infection. C. Infiltration. D. Circulatory overload.

Correct Answer is C

Explanation

Choice A rationale:

Phlebitis is inflammation of a vein, often associated with pain, redness, and warmth at the catheter site. In this case, the client's catheter site is described as cool and taut, which is not consistent with the manifestations of phlebitis.

Choice B rationale:

Infection typically presents with signs such as redness, warmth, swelling, and pain at the catheter site. The description of the client's catheter site as cool and taut is not indicative of infection.

Choice C rationale:

The client's symptoms, including a cool and taut catheter site and IV fluid leaking, are indicative of infiltration. Infiltration occurs when IV fluids inadvertently enter the surrounding tissue instead of the vein. It can lead to localized swelling and discomfort.

Choice D rationale:

Circulatory overload is characterized by symptoms such as shortness of breath, elevated blood pressure, and tachycardia. These symptoms are not consistent with the client's description of a cool and taut catheter site with IV fluid leaking.

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A nurse is planning care for clients. Which of the following tasks can the nurse delegate to an assistive personnel (AP)?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to administer lidocaine 50 mg IV bolus. Available is lidocaine 200 mg/mL. How many mL should the nurse administer per dose? rounded off to the nearest hundredth

Correct Answer is B

Explanation

A nurse is assessing a client who is receiving continuous IV therapy through a peripheral IV. The catheter site is cool and taut, and there is IV fluid leaking.The nurse should identify that the client has manifestations of which of the following complications?

Correct Answer is C

Explanation

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A nurse is planning care for clients.
Which of the following tasks can the nurse delegate to an assistive personnel (AP)?