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 D
Explanation
Rationale:
A. A client who reports pain as 4 on a scale of 1 to 10 at 0800 now reports pain as 6 needs pain management, but this is less urgent compared to potential signs of hypotension.
B. A client whose wound drainage at 0800 was sanguineous and now it is serosanguineous indicates normal progression of wound healing; thus, it is less critical.
C. A client who has a prescription for insulin and his premeal capillary blood glucose was 110 mg/dL and his post-meal capillary blood glucose is now 160 mg/dL needs blood glucose management, but this is less urgent than assessing for potential hypovolemia or shock.
D. A client whose blood pressure at 0800 was 138/86 mm Hg and at 1200 is 106/60 mm Hg is experiencing a significant drop in blood pressure, which could indicate hypovolemia or shock. This requires immediate assessment and intervention to prevent complications.
Correct Answer is B
Explanation
Rationale:
A. Requesting a referral is important but not immediately critical compared to other needs.
B. Asking about a PCA pump with morphine indicates a potential issue with pain management or medication delivery that needs immediate attention.
C. Assisting with a bath is important for comfort and hygiene but is less urgent compared to immediate pain management.
D. Questions about a new prescription should be addressed but are generally less urgent than issues related to pain management.
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