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
Choice A reason:
"Repeat the dose if your child vomits within 1 hour after taking the medication." This statement is incorrect. If a child vomits within 1 hour after taking digoxin, the parents should not repeat the dose. The reason is that the child may have already absorbed a sufficient amount of the medication before vomiting, and an additional dose could lead to digoxin toxicity.
Choice B reason:
"You can add the medication to a half-cup of your child's favourite juice." This statement is incorrect. Adding digoxin to juice or any other food or drink is not recommended. Digoxin should be administered separately and not mixed with food or liquids to ensure accurate dosing and prevent potential interactions with other substances.
Choice C reason:
"Have your child drink a small glass of water after swallowing the medication." This statement is correct. Giving a small glass of water after administering digoxin helps ensure that the medication is fully swallowed and goes into the stomach, reducing the risk of it being retained in the mouth or throat.
Choice D reason:
"Limit your child's potassium intake while she is taking this medication." This statement is not accurate. Digoxin is often prescribed in conjunction with other heart failure medications, some of which may impact potassium levels. However, the parents should not arbitrarily limit the child's potassium intake without specific instructions from the healthcare provider. The healthcare provider will monitor the child's potassium levels and adjust the treatment plan as necessary.
Correct Answer is D
Explanation
Choice A reason:
"I should gargle with an alcohol-based mouthwash to kill germs”. This statement is not appropriate. Using an alcohol-based mouthwash is not recommended for a client with stomatitis. Alcohol can be irritating to the already inflamed mucous membranes and may worsen the condition. Instead, the client should use a mild, non-alcohol-based mouthwash or rinse as prescribed by the healthcare provider.
Choice B option
"I should limit my intake of dairy products to prevent nausea." This statement is not appropriate. While some clients may experience nausea during radiation therapy, limiting dairy products is not specifically related to stomatitis management. The client should follow any dietary recommendations provided by the healthcare provider or a registered dietitian to address nausea or other dietary concerns.
Choice C option
"I should moisten my lips with lemon-glycerine swabs." This is incorrect because lemon-glycerine swabs can be drying and irritating to the oral mucosa, which may exacerbate stomatitis symptoms. Instead, using a gentle, non-irritating lip balm or petroleum jelly is preferred.
Choice D option
"I should use a soft-bristle toothbrush to clean my teeth after meals. “This response indicates an understanding of the teaching because a soft-bristle toothbrush is gentle on the gums and oral tissues, which is important for a client with stomatitis, as it helps to minimize irritation and injury.
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