A nurse is reviewing the provider's prescriptions for a client who has a positive sputum culture for tuberculosis. Which of the following tasks should the nurse delegate to an assistive personnel (AP)?
Collect the client's urine output every 24 hours
Administer the client's scheduled antitubercular medications
Assist the client with speech therapy exercises
Place the client on airborne precautions
The Correct Answer is A
Choice A reason: Collecting the client's urine output every 24 hours is a task that the nurse can delegate to an AP. This task is within the AP's scope of practice and does not require clinical judgment or assessment. The nurse should provide clear instructions and expectations to the AP, and monitor and evaluate the client's fluid status and renal function.
Choice B reason: Administering the client's scheduled antitubercular medications is a task that the nurse cannot delegate to an AP. This task is outside the AP's scope of practice and requires clinical judgment and assessment. The nurse should follow the five rights of medication administration and monitor the client for adverse effects and therapeutic outcomes.
Choice C reason: Assisting the client with speech therapy exercises is a task that the nurse cannot delegate to an AP. This task is outside the AP's scope of practice and requires specialized knowledge and skills. The nurse should collaborate with the speech therapist and follow the prescribed plan of care for the client.
Choice D reason: Placing the client on airborne precautions is a task that the nurse cannot delegate to an AP. This task is outside the AP's scope of practice and requires clinical judgment and assessment. The nurse should implement the infection control measures and educate the client and the AP about the rationale and the procedures.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: A client who has a displaced femur fracture from a fall is a priority client, but not the highest priority. The nurse should assess the client for signs of bleeding, infection, nerve damage, and compartment syndrome, and provide pain relief and immobilization. However, the client's condition is not as urgent or life-threatening as the other clients.
Choice B reason: A client who is experiencing severe vomiting and diarrhea with tachycardia is a priority client, but not the highest priority. The nurse should assess the client for signs of dehydration, electrolyte imbalance, and shock, and provide fluid and electrolyte replacement and antiemetic medication. However, the client's condition is not as urgent or life-threatening as the other clients.
Choice C reason: A client who is confused and has slurred speech is the highest priority client, as these are signs of a possible stroke, which is a medical emergency. The nurse should assess the client for other signs of stroke, such as facial drooping, arm weakness, and vision problems, and initiate the stroke protocol, which includes calling for help, obtaining a CT scan, and administering thrombolytic therapy if indicated.
Choice D reason: A client who has chemical burns covering 20% of the total body surface area is a priority client, but not the highest priority. The nurse should assess the client for signs of airway injury, infection, and fluid loss, and provide wound care, pain relief, and fluid resuscitation. However, the client's condition is not as urgent or life-threatening as the other clients.
Correct Answer is B
Explanation
Choice A reason: The belief that the client has a difficult relationship with his son is not relevant for the change-of-shift report. This is a subjective and personal opinion that does not affect the client's care or recovery.
Choice B reason: The steps to follow when providing wound care is relevant for the change-of-shift report. This is an objective and clinical information that ensures the continuity and quality of the client's care.
Choice C reason: The time the client received his last dose of pain medication is not relevant for the change-of-shift report. This is a routine and standard information that can be found in the medication administration record or the electronic health record.
Choice D reason: The client's preferred time for bathing is not relevant for the change-of-shift report. This is a preference and not a priority information that can be communicated later or documented in the care plan.
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