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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Correct Answer is C

Explanation

The correct answer and explanation is:

c. Denial

The nurse should identify that the client is experiencing the stage of denial in the grief process. Denial is a common psychological defense mechanism that individuals may exhibit when faced with a stressful or overwhelming situation, such as the prospect of open heart surgery. It involves a refusal to accept or acknowledge the reality of the situation. In this case, the client's statement of being confident to go home shortly after surgery demonstrates a denial of the potential challenges and recovery process associated with such a procedure.

Explanation for the other options:

A . Anger: Anger is a stage of grief characterized by feelings of resentment, frustration, and hostility. It is common for individuals to experience anger as part of the grief process, but the client's statement does not indicate anger.

B. Depression: Depression is another stage of grief marked by feelings of sadness, hopelessness, and loss. While it is normal for individuals to experience some level of anxiety or sadness before undergoing surgery, the client's statement does not specifically reﬂect depression.

d. Acceptance: Acceptance is the final stage of grief, where individuals come to terms with their situation and find a sense of peace or resolution. The client's statement indicates a lack of acceptance as they are denying the potential impact of the surgery and its recovery process.

A. Puncture the heel to a depth of 4 mm to obtain the specimen. B. Withhold feeding prior to collecting the specimen. C. Apply a heat pack 5 to 10 minutes prior to the procedure. D. Elevate the newborn's foot for 15 minutes following the procedure.

Correct Answer is C

Explanation

The nurse should apply a heat pack 5 to 10 minutes prior to the procedure when planning to obtain blood from a newborn via a heel stick. This helps to increase blood ﬂow to the area and makes it easier to obtain the specimen.

a) Puncturing the heel to a depth of 4 mm is too deep and can cause injury to the newborn. The recommended depth for a heel stick is 2.4 mm or less.

b) Withholding feeding prior to collecting the specimen is not necessary.

d) Elevating the newborn's foot for 15 minutes following the procedure is not necessary.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is scheduled for open heart surgery. The client states, "I am confident I will be able to go home a few hours after the surgery." The nurse should identify that the client is experiencing which of the following stages of grief?

Correct Answer is C

Explanation

The correct answer and explanation is:

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

Correct Answer is C

Explanation

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