A nurse is planning to assign tasks for a group of clients.Which of the following tasks should the nurse plan to assign to an assistive personnel (AP)? (Select all that apply)
Weigh a client who has heart failure.
Provide discharge instructions for a client who has a new skin graft.
Perform an admission assessment on a client.
Ambulate an older adult client who has hypertension.
Check a blood product with another nurse prior to administration.
Correct Answer : A,D
Choice A rationale
Weighing a client with heart failure is a non-invasive and routine task that can be performed by an assistive personnel (AP). Accurate daily weights are essential for monitoring fluid balance in these clients.
Choice B rationale
Incorrect, as providing discharge instructions for a client requires professional nursing judgment and assessment, tasks outside the scope of practice for APs.
Choice C rationale
Incorrect, as performing an admission assessment requires critical thinking and clinical judgment, which are responsibilities of a licensed nurse.
Choice D rationale
Ambulating an older adult client with hypertension can be safely done by an AP. This helps in maintaining the client's mobility and preventing complications such as blood clots and muscle atrophy.
Choice E rationale
Incorrect, as checking a blood product with another nurse prior to administration involves a critical safety check that must be performed by licensed nurses to ensure the right blood is given to the right patient.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","E"]
Explanation
Choice A rationale
Resistance to the flow of IV fluid may indicate infiltration or extravasation, where the medication leaks into surrounding tissues, necessitating stopping the infusion.
Choice B rationale
Burning or pain, swelling, or redness at the site are signs of extravasation, which is a serious complication of vincristine administration and requires immediate action.
Choice C rationale
Reporting anxiety and depression are not directly related to vincristine infusion site complications. These are more systemic effects and do not indicate the need to stop the infusion immediately.
Choice D rationale
Nausea and vomiting are common side effects of vincristine but do not indicate a problem with the IV line itself, so they do not require stopping the infusion.
Choice E rationale
Absence of blood return from the IV catheter may indicate that the catheter is not in the vein properly, which requires stopping the infusion to prevent tissue damage.
Correct Answer is D
Explanation
Choice A rationale
Cervical cancer screening is recommended for individuals with a cervix starting at age 21, not necessarily for detecting colorectal cancer. It's an essential screening but irrelevant to middle-aged clients discussing colorectal cancer risk.
Choice B rationale
Lung cancer screening is mainly for people with a history of heavy smoking. Discussing lung cancer screening with a doctor is vital, but it does not address the early detection of colorectal cancer for average-risk individuals.
Choice C rationale
The previous recommendation was to start colorectal cancer screening at age 50. However, guidelines have updated, and this age is now considered outdated for average-risk individuals.
Choice D rationale
Colorectal cancer screening for everyone beginning at age 45 aligns with the latest American Cancer Society guidelines. This change reflects evidence showing the benefit of earlier screening to detect and prevent colorectal cancer in average-risk adults.
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