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?
Changing the appliance on a new colostomy
Performing indwelling urinary catheter care
Demonstrating how to use an incentive spirometer
Measuring the depth of a stage 3 pressure injury
The Correct Answer is B
The correct answer is choice b. Performing indwelling urinary catheter care.
Choice A rationale:
Changing the appliance on a new colostomy is a complex task that requires assessment and education, which should be performed by a registered nurse (RN) or a licensed practical nurse (LPN).
Choice B rationale:
Performing indwelling urinary catheter care is a routine task that can be delegated to an assistive personnel (AP) as it involves basic hygiene and maintenance.
Choice C rationale:
Demonstrating how to use an incentive spirometer involves patient education and assessment of the patient’s technique, which should be done by an RN or LPN.
Choice D rationale:
Measuring the depth of a stage 3 pressure injury requires assessment skills and clinical judgment, which are beyond the scope of practice for an AP. This task should be performed by an RN or LPN.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The correct answer is choice C. The AP pulls the pinna up and back.
Choice A rationale:
Inserting the probe with a straightforward motion is not sufficient to ensure an accurate reading. Proper positioning of the ear canal is necessary to get an accurate tympanic temperature.
Choice B rationale:
Positioning the client facing the AP is not relevant to the accuracy of the tympanic temperature measurement. The focus should be on the correct technique for inserting the probe.
Choice C rationale:
Pulling the pinna up and back is the correct technique for adults and children over 3 years old. This action straightens the ear canal, allowing for an accurate temperature reading.
Choice D rationale:
Pointing the probe posteriorly is not a standard guideline for taking a tympanic temperature. The probe should be aimed towards the eardrum for an accurate measurement.
Correct Answer is D
Explanation
The correct answer is D.
Chadwick's sign. Chadwick's sign is a bluish discoloration of the cervix, vagina, and vulva caused by increased blood flow to these areas during pregnancy. It usually appears around 6 to 8 weeks of gestation and persists until delivery. It is one of the presumptive signs of pregnancy, which are subjective changes that suggest pregnancy but are not conclusive. Ballottement is a technique of palpating the uterus to detect fetal movement when a finger is inserted into the vagina and tapped against the cervix. It can be performed between 16 and 28 weeks of gestation and is also a presumptive sign of pregnancy.
Chloasma is a condition characterized by brown patches on the face that may occur during pregnancy due to hormonal changes. It is also known as melasma or mask of pregnancy and usually fades after delivery. Hegar's sign is a softening of the lower uterine segment that can be felt during bimanual examination around 6 weeks of gestation. It is one of the probable signs of pregnancy, which are objective changes that strongly indicate pregnancy but are not diagnostic.
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