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 ["A","B","E"]

Explanation

Compartment syndrome is a condition characterized by increased pressure within a closed anatomical space, such as a compartment in the leg. This increased pressure can compromise blood ﬂow and nerve function. When assessing a client with a long-leg cast who reports severe pain, the nurse should be vigilant for signs and symptoms of compartment syndrome.

Option a is a correct answer because pallor (paleness) in the exposed portion of the left foot may indicate compromised blood ﬂow due to increased pressure within the compartment.

Option b is a correct answer because the inability to move the left foot suggests impaired nerve function,

which can be a sign of compartment syndrome.

Option c is not a correct answer. Increased warmth is not typically associated with compartment syndrome; instead, it may suggest inﬂammation or infection.

Option d is not a correct answer. Ecchymosis (bruising) is not typically associated with compartment syndrome, as it is more commonly observed in cases of injury or trauma.

Option e is a correct answer because paresthesia (abnormal sensations like tingling or numbness) in the left foot can indicate nerve compression and is a potential symptom of compartment syndrome.

By identifying the presence of pallor, inability to move the foot, and paresthesia, the nurse can recognize indications of compartment syndrome and take appropriate actions to address the condition promptly.

A. Soiled linens are placed on the floor. B. Uncapped sharps are put in a puncture-resistant container. C. Dampened cloths are used for dusting the area. D. Waste containers are lined with single bags.

Correct Answer is A

Explanation

Immunocompromised individuals have a weakened immune system, which makes them more susceptible to infections. Soiled linens, when placed on the floor, can potentially harbor pathogens and become a source of contamination. It is essential to handle soiled linens properly by placing them in designated containers or bags to prevent the spread of infectious agents.

Uncapped sharps put in a puncture-resistant container: This is the correct practice for disposing of sharps, such as needles or lancets. Uncapped sharps should always be placed in puncture-resistant containers to prevent accidental injuries and potential transmission of infections.

Dampened cloths used for dusting the area: Dampened cloths for dusting can help minimize the dispersal of dust and allergens, but it does not necessarily pose a significant risk of infection.

However, it is important to ensure that the dampened cloths are properly cleaned and sanitized to prevent the growth and spread of microorganisms.

Waste containers lined with single bags: Waste containers lined with single bags are a common practice for proper waste management and disposal. While it is important to maintain good waste management practices to prevent the spread of infections, the use of single bags alone does not significantly affect the risk of infection for immunocompromised clients.

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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

A nurse is collecting data from a client who has a long-leg cast on his left leg and reports severe pain. Which of the following findings should the nurse identify as an indication that the client might have compartment syndrome? (Select all that apply.)

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

Explanation

A nurse is providing care to a client who is immunocompromised. Which of the following should the nurse identify as a possible source of infection?

Correct Answer is A

Explanation

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