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? (Select all that apply.)

Ambulate a client who has a cane.

Demonstrate the technique to instill eye drops.

Record urinary output.

Irrigate a wound.

Transfer a client to a stretcher.

Answer and Explanation

Correct Answer : A,C,E

A. Ambulate a client who has a cane: Ambulating a stable client is a standard skill (ADL) that does not require nursing assessment.

B. Demonstrate the technique to instill eye drops: "Demonstrating" implies teaching. Teaching and evaluating learning are the exclusive responsibilities of the RN and cannot be delegated to an AP.

C. Record urinary output: Assistive Personnel can collect data (measure volume) and record it. The RN then analyzes that data (assessment).

D. Irrigate a wound: Wound irrigation is a sterile or clean procedure that requires assessment of the wound bed and skin integrity. This is a nursing skill.

E. Transfer a client to a stretcher: Transfers and mobility assistance are standard skills within the AP's scope of practice, provided the client is stable.

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

Explanation

A. Fine hand tremors and pill rolling:This is a symptom of Pseudoparkinsonism, an early extrapyramidal side effect (EPS), not Tardive Dyskinesia (TD).

B. Facial grimacing and eye blinking: Tardive Dyskinesia (TD) is a late-onset, often irreversible side effect of long-term antipsychotic use. It typically begins with involuntary movements of the face and neck, such as excessive blinking and grimacing.

C. Tongue thrusting and lip smacking: These are the classic "oro-buccal-lingual" movements associated with TD. The client may also puff their cheeks or chew continuously.

D. Involuntary pelvic rocking and hip thrusting movements: TD can also affect the trunk and extremities, causing slow, twisting movements (choreoathetoid movements) or rocking.

E. Urinary retention and constipation: These are anticholinergic side effects, which are common with antipsychotics but are not related to movement disorders like TD.

A. Weak pulses B. Murmur C. Hypotension D. Bradycardia E. Clubbing of the nail beds

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

Explanation

A. Weak pulses: Aortic stenosis involves the narrowing of the aortic valve, which obstructs blood flow from the left ventricle into the aorta (systemic circulation). Because less blood is being ejected, the peripheral pulses will be weak or thready.

B. Murmur:As blood is forced through the narrowed, stiff valve, it creates turbulence. This turbulence produces a characteristic systolic ejection murmur.

C. Hypotension:Due to the obstruction of blood flow, cardiac output decreases. This drop in the volume of blood entering the arteries leads to low blood pressure (hypotension) and a narrowed pulse pressure.

D. Bradycardia:The heart actually has to work harder to pump blood against the resistance of the narrowed valve. Additionally, the body attempts to compensate for the decreased cardiac output by increasing the heart rate (tachycardia), not decreasing it.

E. Clubbing of the nail beds:Clubbing is typically associated with chronic hypoxia found in cyanotic heart defects (right-to-left shunts) or chronic pulmonary disease. Aortic stenosis is an acyanotic defect; oxygen saturation typically remains normal unless severe heart failure develops.

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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? (Select all that apply.)

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