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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["5.3"]
Explanation
- Convert weight to kilograms: 28 lb ÷ 2.2 = 12.73 kg (approx. 12.7 kg)
- Calculate dose: 12.7 kg × 10 mg/kg = 127 mg
- Determine volume: 120 mg / 5 mL = 24 mg/mL
- 127 mg ÷ 24 mg/mL = 5.29 mL
- Rounded to nearest tenth: 5.3 mL
Correct Answer is ["B","E"]
Explanation
A. Tremors:
Common symptom of hyperthyroidism due to increased adrenergic activity, but typically not life-threatening. Managed with beta-blockers; lower risk compared to major complications.
B. Thyroid storm:
Acute, life-threatening exacerbation with high fever, severe tachycardia, altered mental status, and potential organ failure. Requires immediate ICU-level care; highest-risk complication.
C. Insomnia:
Frequent symptom from hypermetabolism and anxiety, but not a major complication. It impacts quality of life rather than posing immediate danger.
D. Excessive sweating:
Typical manifestation of increased metabolic rate and heat intolerance. Uncomfortable but not dangerous; manageable with symptom control.
E. Dysrhythmias:
Hyperthyroidism can precipitate atrial fibrillation and other tachyarrhythmias, increasing risk of thromboembolism and hemodynamic instability. Significant morbidity risk, especially in older adults.
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