A nurse is planning to delegate client care tasks to an assistive personnel (AP). Which of the following tasks should the nurse plan to delegate to the AP?
Perform gastrostomy feedings through a client's established gastrostomy tube
Determine if the PRN pain medication administered 30 min ago has helped
Provide instructions about client care to a family member over the telephone
Teach a client how to measure their own blood pressure
The Correct Answer is A
A. Performing gastrostomy feedings through an established gastrostomy tube is within the scope of practice for an AP, as it is a routine, non-complex task.
B. Evaluating the effectiveness of pain medication requires assessment skills, which fall under the nurse’s scope of practice.
C. Providing client care instructions requires nursing judgment and should be done by the nurse.
D. Teaching a client how to measure their blood pressure involves client education, which is the nurse’s responsibility.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
Taking corrective measures to enforce hand hygiene should not be the first step. It is important to establish a baseline and understand the current situation through data collection and analysis before implementing corrective measures.
Choice B rationale:
Establishing methods for collecting data within the facility is a crucial first step. Gathering information about the current hand hygiene practices, compliance rates, and areas of improvement is essential for the audit process. Data collection provides a factual basis for identifying problems and implementing targeted interventions.
Choice C rationale:
Comparing the facility's data with the established criteria for hand hygiene is a subsequent step after data collection. This step helps in evaluating the current practices against the accepted standards and guidelines. However, it is not the first step in the audit process.
Choice D rationale:
Determining the accepted standards for hand hygiene is an essential first step. It involves researching and understanding the national and international guidelines, protocols, and recommendations related to hand hygiene. Knowing the standards helps the task force establish a benchmark against which the facility's practices can be evaluated. It provides a foundation for data collection and subsequent analysis.
Correct Answer is A
Explanation
Choice A rationale:
The nurse should include the statement, "Use a product with DEET on your skin and clothes when you are walking in a wooded area," in the educational program on Lyme disease. DEET is a widely used insect repellent effective against ticks. It is recommended to prevent tick bites in wooded and grassy areas. The rationale behind this choice is to educate the public about practical measures to reduce the risk of Lyme disease. DEET repels ticks, reducing the chances of tick attachment and, consequently, the transmission of Lyme disease.
Choice B rationale:
The statement, "Symptoms of Lyme disease appear 2 days after being bitten by an infected tick," is incorrect. The incubation period for Lyme disease can vary from 3 to 30 days after the tick bite. Symptoms usually appear within 3 to 14 days but can take longer to manifest. Providing inaccurate information can lead to misunderstanding and inadequate preventive measures.
Choice C rationale:
The statement, "Remove embedded ticks by squeezing the body with tweezers," is incorrect. Improper removal of ticks, such as squeezing the body, can lead to the injection of tick fluids into the host, increasing the risk of disease transmission. The correct method for tick removal is to use fine-tipped tweezers to grasp the tick as close to the skin's surface as possible and pull upward with steady, even pressure. This helps ensure the tick is removed entirely and reduces the risk of infection.
Choice D rationale:
The statement, "If bitten by a tick, testing for Lyme disease should occur within 2 weeks," is incorrect. Testing for Lyme disease immediately after a tick bite is not recommended because it takes time for the body to produce antibodies detectable by the tests. Testing too early can yield false-negative results. Healthcare providers may recommend testing if symptoms develop, but waiting for a few weeks after the bite increases the accuracy of the test results.
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