A nurse is preparing to assign tasks to an assistive personnel (AP). Which of the following tasks should the nurse assign to the AP?

Verifying placement of a nasogastric tube.

Evaluating a client's understanding of how to use crutches.

Replacing the gauze on a skin abrasion.

Monitoring bowel sounds.

Answer and Explanation

The Correct Answer is C

Choice A rationale:

Verifying placement of a nasogastric tube requires specialized training and knowledge to ensure correct placement and prevent complications. The nurse should retain this task to ensure patient safety.

Choice B rationale:

Evaluating a client's understanding of how to use crutches involves assessing the client's comprehension and ability to use crutches safely and effectively. This task requires nursing judgment and should not be delegated to an assistive personnel.

Choice C rationale:

Replacing the gauze on a skin abrasion is a task that can be safely assigned to an assistive personnel. It involves basic wound care, which typically falls within the scope of practice for assistive personnel. The AP can be trained to follow established protocols for wound cleaning and dressing changes.

Choice D rationale:

Monitoring bowel sounds requires clinical judgment and the ability to recognize variations from the normal range. The nurse should perform this task, as it involves assessing the client's condition and making appropriate decisions based on the findings.

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Correct Answer is C

Explanation

Choice A rationale:

Performing oral care once each day is not sufficient to reduce the risk of ventilator-associated pneumonia (VAP). Ventilated patients are at an increased risk of developing VAP due to the presence of an endotracheal tube that bypasses the body's natural defenses. Bacteria can accumulate in the mouth and respiratory tract, leading to pneumonia. Therefore, performing oral care only once a day is inadequate for maintaining oral hygiene and preventing VAP.

Choice B rationale:

Brushing the client's teeth with a firm-bristle toothbrush can cause trauma to the oral tissues, potentially leading to bleeding and irritation. In critically ill patients with an endotracheal tube, using a firm-bristle toothbrush can exacerbate the risk of infection and VAP. It is essential to use gentle and non-traumatic methods for oral care to maintain the integrity of the oral mucosa.

Choice C rationale:

Swabbing the client's mouth with chlorhexidine solution is the correct choice. Chlorhexidine is an antiseptic solution that effectively reduces the growth of bacteria in the oral cavity. Regular use of chlorhexidine mouthwash has been shown to decrease the risk of VAP in mechanically ventilated patients. By reducing the bacterial load in the mouth, the risk of aspiration and subsequent pneumonia is lowered, making it a crucial intervention for preventing VAP.

Choice D rationale:

Raising the head of the bed by 15° for oral care is an important measure to prevent aspiration during oral care. However, it alone is not sufficient to reduce the risk of VAP. While proper head positioning helps prevent the entry of oral secretions into the lower respiratory tract, it must be combined with effective oral hygiene practices, such as using chlorhexidine solution, to comprehensively reduce the risk of VAP.

A. Schedule the client as the last surgery of the day. B. Notify ancillary departments of the client's allergy. C. Label the surgical suite as latex-free. D. Provide powdered gloves for the staff's use. E. Ensure a latex allergy cart is available.

Correct Answer is ["B","C","E"]

Explanation

Choice A rationale:

Scheduling the client as the last surgery of the day is not directly related to the client's latex allergy. It might not be feasible to always schedule the client last, and this action does not specifically address the client's needs related to latex exposure.

Choice B rationale:

Notifying ancillary departments of the client's latex allergy is an important step to ensure the client's safety during the surgical process. This action helps other departments prepare and prevent accidental latex exposure, which could trigger an allergic reaction in the client.

Choice C rationale:

Labeling the surgical suite as latex-free is crucial to preventing latex exposure during the surgery. It alerts all staff members entering the surgical suite about the presence of a latex-allergic patient and reminds them to take appropriate precautions.

Choice D rationale:

Providing powdered gloves for the staff's use is not recommended, as powdered gloves can actually carry latex proteins and increase the risk of latex exposure. Powdered gloves have been associated with allergic reactions, so it's important to avoid their use in a latex-sensitive environment.

Choice E rationale:

Ensuring a latex allergy cart is available is a proactive measure to have necessary equipment and supplies on hand in case of an allergic reaction. This cart would contain latex-free items and medications that can be used to manage an allergic reaction should it occur during or after surgery.

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A nurse is preparing to assign tasks to an assistive personnel (AP). Which of the following tasks should the nurse assign to the AP?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is planning care for a client who has an endotracheal tube and is receiving mechanical ventilation. Which of the following interventions should the nurse include to reduce the client's risk for ventilator-associated pneumonia?

Correct Answer is C

Explanation

A nurse is completing a preadmission interview for a client who is to undergo surgery the following day. The client reports a latex allergy. Which of the following interventions should the nurse include when planning care for the client's surgery? (Select all that apply)

Correct Answer is ["B","C","E"]

Explanation

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