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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is D

Explanation

d. Apply the dressing loosely over the incision.

Explanation:

The correct answer is d. Apply the dressing loosely over the incision.

When caring for an older adult client, it is important for the nurse to be sensitive to age-related changes and promote their comfort and well-being. Applying the dressing loosely over the incision allows for beter circulation and ventilation, which can help prevent complications such as skin breakdown and infection.

Option a is not the correct answer. Asking the client to help with the dressing change may not be appropriate, as postoperative clients, especially older adults, may have limited mobility or dexterity. It is the nurse's responsibility to provide the necessary care and support during the dressing change.

Option b is not the correct answer. Waiting for the client to approach the nurse for assistance may lead to delays in care and could potentially compromise the client's healing process. The nurse should proactively assess the client's needs and provide appropriate care.

Option c is not the correct answer. Using paper tape for securing the new dressing does not specifically address sensitivity to age-related changes. While paper tape may be gentle on the skin, it is not the primary consideration in this situation.

By applying the dressing loosely over the incision, the nurse demonstrates sensitivity to age-related changes and promotes the client's comfort and optimal healing. This approach takes into account the potential for decreased skin elasticity and fragility in older adults, allowing for proper circulation and reducing the risk of complications.

A. The client's foot feels cooler than in the previous assessment. B. The client's pedal pulse in the right foot is not palpable. C. The client's capillary refill time is 5 seconds in the toes. D. The client reports a pain level of 8 on a scale from 0 to 10.

Correct Answer is B

Explanation

The most concerning finding in the assessment of a client's right leg after a femoropopliteal bypass graft would be if the client's pedal pulse in the right foot is not palpable. This could indicate a problem with blood ﬂow to the limb.

The other options are also concerning and should be reported to the healthcare provider.

a) A cooler footmay indicate decreased blood ﬂow to the limb.

c) A capillary refill time of 5 secondsmay also indicate decreased blood ﬂow.

d) A pain level of 8 on a scale from 0 to 10should also be reported and addressed.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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 caring for an older adult client who is postoperative following a total hip arthroplasty. The nurse is preparing to change the client's surgical dressing. Which of the following actions should the nurse take to demonstrate sensitivity to age-related changes?

Correct Answer is D

Explanation

A nurse is establishing a baseline postoperative assessment for a client who is recovering from a right femoropopliteal bypass graft. Which of the following findings in the assessment of the client's right leg should be of the most concern to the nurse?

Correct Answer is B

Explanation

A nurse is planning to obtain blood from a newborn via a heel stick. Which of the following actions should the nurse take?

A nurse is collecting data from a 3-month-old infant who is 6 hr postoperative following a cleft palate repair. Which of the following pain rating tools should the nurse use?

A nurse is preparing to insert a nasogastric tube for a client who has a prescription for gastric decompression. Which of the following supplies should the nurse obtain prior to the procedure?

A nurse is reinforcing teaching about home safety with the parent of an 8-month-old infant. Which of the following statements by the parent indicates an understanding of the teaching?

A nurse is contributing to the plan of care for a client who has Parkinson's disease. Which of the following interventions should the nurse plan to include?

A nurse is preparing to administer a liquid medication to a 6-month-old infant who is crying. Which of the following actions should the nurse take to reduce the risk of aspiration?

A nurse is reinforcing teaching with a client who has a new prescription for digoxin to treat heart failure. Which of the following should the nurse include as an expected eﬀect of this medication?

A nurse is collecting a sputum specimen from a client for culture and sensitivity. Which of the following actions should the nurse take?