A nurse on a medical-surgical unit is assigning tasks to an assistive personnel (AP). Which of the following tasks should the nurse delegate to the AP?

Performing indwelling urinary catheter care

Demonstrating how to use an incentive spirometer

Measuring the depth of a stage 3 pressure injury

Changing the appliance on a new colostomy

Answer and Explanation

The Correct Answer is A

Delegating tasks involves assigning appropriate responsibilities to assistive personnel based on their level of training, competency, and scope of practice. Performing indwelling urinary catheter care is a task that can be safely delegated to an AP who has received proper training and demonstrated competency in this skill. The nurse should ensure that the AP is familiar with the facility's policies and procedures regarding catheter care and can perform the task safely and effectively.

Demonstrating how to use an incentive spirometer requires specialized knowledge and the ability to provide clear instructions. It is typically within the scope of practice of licensed healthcare professionals, such as nurses or respiratory therapists, who have the necessary expertise to properly educate and guide patients in using an incentive spirometer. This task should not be delegated to an AP.

Measuring and assessing the depth of a pressure injury requires clinical judgment and accurate evaluation, which falls within the scope of practice of a licensed nurse. It involves understanding wound assessment, proper technique for measuring depth, and interpreting the findings. This task should be performed by the nurse rather than an AP.

Changing the appliance on a new colostomy involves skills such as assessing the stoma, selecting the appropriate appliance, and ensuring proper application. This task requires specialized knowledge and training in stoma care, and it should be performed by a licensed nurse who has the expertise in managing ostomies. It should not be delegated to an AP.

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Correct Answer is B

Explanation

The therapeutic relationship can be described in terms of four sequential phases: preinteraction phase, introduction/orientation phase, working phase, and termination phase . In the working phase, most of the therapeutic interventional activities are carried out . This is the phase where the nurse should help the client develop problem-solving skills.

The other options are not correct because:

a) The preinteraction phase starts when the nurse is given the responsibility to start a therapeutic relationship with a patient.

c) The introduction/orientation phase is the first meeting of the nurse with her client (patient).

d) The termination phase is the final stage of the nurse-client relationship.

A. Start the first patch on the seventh day of the menstrual cycle. B. The contraceptive eﬀect will continue for 6 months following discontinuation of the medication C. Apply the patch to the lower abdomen D. Expect to have a headache during the first month

Correct Answer is C

Explanation

a. "Start the first patch on the seventh day of the menstrual cycle."

Explanation:

The correct answer is a. "Start the first patch on the seventh day of the menstrual cycle."

When providing teaching about a combination contraceptive transdermal patch, it is important to provide accurate and relevant information to ensure its eﬀectiveness and proper use.

Option b is not the correct answer. The contraceptive eﬀect of the transdermal patch does not continue for 6 months following discontinuation. Its eﬀectiveness lasts only as long as the client continues to use it according to the prescribed schedule.

Option c is not the correct answer. The transdermal patch should be applied to a clean, dry area of the skin that is free from cuts, rashes, or irritation. The lower abdomen is not a recommended site for application.

Option d is not the correct answer. While headaches can occur as a side eﬀect of hormonal contraceptives, it is not necessary to expect a headache during the first month. Side eﬀects can vary among individuals, and it is important to monitor and report any concerning symptoms to the healthcare provider.

By instructing the client to start the first patch on the seventh day of the menstrual cycle, the nurse provides specific guidance on when to initiate the contraceptive method. This ensures that the client is starting the patch at an appropriate time in their menstrual cycle, optimizing its eﬀectiveness

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A nurse on a medical-surgical unit is assigning tasks to an assistive personnel (AP). Which of the following tasks should the nurse delegate to the AP?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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Correct Answer is C

Explanation

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