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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Related Questions

A. Constipation: Constipation is not a common or significant side effect of cefazolin. While antibiotics can sometimes cause gastrointestinal disturbances such as diarrhea or nausea, constipation is unlikely to be a major concern for this medication. The adolescent should be encouraged to maintain hydration and a balanced diet, but constipation is not a priority symptom to report in this case. B. Elevated skin patches: Elevated skin patches or rashes could be a sign of an allergic reaction to cefazolin, but this is not the most immediate or critical symptom to monitor for in the context of the question. If an allergic rash develops, the adolescent should certainly report it, but elevated skin patches are more general and not directly associated with a serious or common side effect of cefazolin. Immediate concerns would be other signs of an allergic reaction, such as swelling or difficulty breathing. C. Ringing in the ears: Ringing in the ears (tinnitus) can be a sign of ototoxicity, a known side effect of cefazolin, especially when administered in high doses or for prolonged periods. Ototoxicity can affect hearing and balance, and tinnitus is an early symptom. This is a serious issue that should be reported immediately, as the drug might need to be adjusted or discontinued to prevent permanent damage to the ears. D. Depression: While depression is a serious condition that can affect adolescents, it is not a known side effect of cefazolin. If an adolescent experiences mood changes or symptoms of depression, these should be addressed, but they are unlikely to be directly related to the medication. Depression should always be taken seriously and managed, but it is not a primary concern related to cefazolin use.

Correct Answer is C

Explanation

c. Ringing in the ears.

Explanation:

Cefazolin is an antibiotic medication that belongs to the class of cephalosporins. While it is generally safe and well-tolerated, it can have potential side eﬀects that should be monitored and reported to the healthcare provider. One of the potential side eﬀects of cefazolin is ototoxicity, which can manifest as ringing in the ears (tinnitus) or other hearing disturbances. If the adolescent experiences any ringing in the ears or changes in hearing while taking cefazolin, it should be reported to the healthcare provider for further evaluation.

Options a, b, and d are not specifically associated with the use of cefazolin. Constipation can occur due to various reasons unrelated to this medication. Elevated skin patches may be indicative of an allergic reaction or other skin condition but are not specific to cefazolin. Depression is not a common side eﬀect of cefazolin and should be evaluated separately if experienced by the adolescent.

A. Aﬀected extremity warm to touch B. Moderate pain on the ankle of the aﬀected extremity C. Blanch time of 2 seconds in the toenail beds of the aﬀected extremity D. Palpation of a +1 dorsal pedal pulse of the aﬀected extremity

Correct Answer is B

Explanation

A nurse collecting data on a client who has swelling of the lower leg should identify that moderate pain on the ankle of the aﬀected extremity is a manifestation of compartment syndrome. Compartment syndrome is a painful condition that occurs when pressure within a muscle compartment increases to dangerous levels.

The other options are not typical symptoms of compartment syndrome.

a) An aﬀected extremity being warm to touchis not a typical symptom of compartment syndrome.

c) A blanch time of 2 seconds in the toenail beds of the aﬀected extremity is not a typical symptom of compartment syndrome.

d) Palpation of a +1 dorsal pedal pulse of the aﬀected extremity is not a typical symptom of

compartment syndrome.

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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?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is B

Explanation

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