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

Answer and Explanation

The Correct Answer is D

A. While an AP may assist with certain feeding tasks, performing gastrostomy feedings typically requires nursing judgment and assessment skills, especially in monitoring for potential complications (e.g., aspiration, tube displacement). This task is usually within the RN’s scope of practice.
B. Incorrect. Determining if the PRN pain medication has helped is an evaluation and should bot be delegated.
C. Incorrect. Providing instructions about client care to a family member over the telephone is a task that requires clinical judgment and communication skills. The nurse should not delegate this task to an AP who might not have the knowledge or authority to answer questions or address concerns.
D. Teaching a client how to measure their own blood pressure can be delegated to an AP, provided that the AP has received proper training on the procedure. This task is more straightforward and does not require the clinical judgment or assessment skills that are necessary for the other options.

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Correct Answer is C

Explanation

Choice A rationale:

Keeping a can of concentrated formula in the refrigerator for 3 days after opening it is not safe. Once a can of formula is opened, it should be used within 24 hours and stored in the refrigerator. After 24 hours, any leftover formula should be discarded to prevent the risk of bacterial contamination.

Choice B rationale:

Diluting ready-to-feed formula with water is incorrect. Ready-to-feed formula is already prepared and does not need to be diluted further. Adding water to ready-to-feed formula can dilute its nutritional content and may not provide the necessary nutrients for the baby.

Choice C rationale:

Boiling tap water for 2 minutes and cooling it before mixing it with powdered formula is the correct method for safe formula preparation. Boiling the water kills harmful bacteria and ensures the formula is safe for the baby to consume. It is essential to cool the boiled water before mixing it with powdered formula to reach an appropriate feeding temperature.

Choice D rationale:

Ensuring that all bottles contain BPA (bisphenol A) is not a relevant consideration for formula preparation. BPA is a chemical that was previously used in some plastics, including baby bottles, but has been banned in baby bottles and sippy cups in several countries due to its potential health risks. Most modern baby bottles are BPA-free, and this statement does not address the safe handling and preparation of formula for the baby.

A. Borderline B. Antisocial C. Paranoid D. Histrionic

Correct Answer is A

Explanation

Borderline.

A. Borderline personality disorder is characterized by a pervasive pattern of instability in interpersonal relationships, self-image, and affect, as well as marked impulsivity and recurrent suicidal behavior. The client's history of seeking counseling for relationship problems and selfinflicted lacerations are consistent with this disorder. Therefore, this choice is correct.
B. Antisocial personality disorder is characterized by a disregard for and violation of the rights of others, as well as a lack of remorse for one's actions. The client's behavior does not indicate this disorder. Therefore, this choice is incorrect.
C. Paranoid personality disorder is characterized by a pervasive distrust and suspiciousness of others, as well as a tendency to interpret others' motives as malevolent. The client's behavior does not indicate this disorder. Therefore, this choice is incorrect.
D. Histrionic personality disorder is characterized by excessive emotionality and attentionseeking behavior, as well as a tendency to dramatize situations and exaggerate emotions. The client's behavior does not indicate this disorder. Therefore, this choice is incorrect.

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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?

Nursing Test Bank

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Explanation

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Explanation

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