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

Answer and Explanation

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.

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Correct Answer is C

Explanation

Choice A option:

Dietitian should not be consulted: The dietitian is an essential team member and will work closely with the client to ensure proper nutrition and dietary management. However, in the context of dysphagia, the speech-language pathologist's expertise is needed to determine safe swallowing strategies and food modifications.

Choice B option:

Physical therapist should not be consulted: The physical therapist focuses on maintaining and improving the client's physical function and mobility. While important in ALS management, the physical therapist's role is not directly related to the immediate issue of dysphagia.

Choice C option:

The speech-language pathologist is the correct answer because it specializes in assessing and treating communication and swallowing disorders. In this case, the speech-language pathologist is essential in evaluating the client's swallowing function, recommending appropriate dietary modifications (texture and consistency of foods), and implementing swallowing exercises or strategies to improve swallowing safety.

Choice D option:

Occupational therapist should not be consulted: The occupational therapist assists clients in regaining or maintaining independence in daily living activities. While the occupational therapist may address some aspects of mealtime activities and adaptive strategies, the speech-language pathologist is more specialized in evaluating and treating swallowing difficulties in clients with ALS.

A. The client has a decreased energy level. B. The client requests a second opinion. C. The client wants to talk about the diagnosis with the nursing staff. D. The client makes funeral arrangements.

Correct Answer is A

Explanation

A. The client has a decreased energy level.A decreased energy level can be a sign of hopelessness, as the client may feel a lack of motivation or purpose due to the terminal nature of the illness. This can manifest as fatigue, lethargy, or a general disinterest in activities.

B. The client requests a second opinion.Requesting a second opinion is generally a sign that the client is still actively engaged in their care and is seeking more information or alternative options. It indicates hope or a desire for different possibilities rather than hopelessness.

C. The client wants to talk about the diagnosis with the nursing staff.Wanting to talk about the diagnosis with the nursing staff suggests that the client is processing the information and seeking support. Open communication is a positive coping mechanism and not typically an indication of hopelessness.

D. The client makes funeral arrangements.Making funeral arrangements can be a practical and proactive approach to dealing with a terminal diagnosis. While it reflects an acceptance of the situation, it does not necessarily indicate hopelessness. Instead, it can show that the client is taking control of their end-of-life decisions.

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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

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Explanation

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