A nurse is planning client care for herself and an assistive personnel (AP) working with her. Which of the following tasks should the nurse plan to perform?
Assisting a client to cough and deep breathe
Application of antiembolic stockings
Administration of an enema
Assessing a client's sacrum for edema
The Correct Answer is D
Rationale:
A. Assisting a client to cough and deep breathe is a task that can be performed by an AP under supervision.
B. Application of antiembolic stockings is within the scope of APs, though it may be monitored by an RN.
C. Administration of an enema typically requires nursing judgment and assessment, making it more appropriate for the RN.
D. Assessing a client’s sacrum for edema requires clinical assessment skills and nursing judgment, which should be performed by an RN.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Rationale:
A. Nurses and emergency medical personnel are trained and designated as triage officers during a disaster, responsible for assessing and prioritizing patients.
B. Law enforcement officers are crucial for security and crowd control but not typically involved in triage.
C. FEMA members provide overall disaster management but are not specifically triage officers.
D. American Red Cross representatives assist with disaster relief but do not handle triage responsibilities directly.
Correct Answer is D
Explanation
Rationale:
A. "There are no provider's prescriptions available." is related to background information but does not describe the current situation of the client.
B. "The client was found unconscious on the floor in her home." provides information about the situation but not the current clinical background.
C. "The client should be seen by a neurologist." is a recommendation for further action and should be included in the "Recommendation" section of SBAR, not "Background."
D. "The client is disoriented. Pupils are slow to respond to light." provides relevant background information about the client's current condition, which is necessary for the SBAR "Background" step.
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