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 ["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.
Correct Answer is B
Explanation
A. Smiles when a parent appears: Social smiling is a normal developmental milestone and not indicative of cerebral palsy.
B. Sits with pillow props: Infants with cerebral palsy may have delayed gross motor development and require support to sit, indicating muscle weakness or abnormal tone.
C. Tracks an object with eyes: Visual tracking is a normal developmental milestone for an 8-month-old.
D. Uses a pincer grasp to pick up a toy: Fine motor milestones such as pincer grasp typically emerge around 9–10 months and are not specific early indicators of cerebral palsy at 8 months.
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