A nurse on a medical-surgical unit is delegating tasks to an assistive personnel (AP). Which of the following client care tasks is within the scope of practice for the AP?

Explaining the steps for a 24-hr urine collection

Interpreting blood glucose values

Performing postmortem care

Assisting with low-carbohydrate diet selections

Answer and Explanation

The Correct Answer is C

A. Explaining the steps for a 24-hr urine collection: Teaching and explaining procedures require nursing knowledge and judgment, which are outside the scope of practice for assistive personnel.

B. Interpreting blood glucose values: Interpretation of lab results requires clinical judgment and assessment skills, which must be performed by a licensed nurse.

C. Performing postmortem care: Postmortem care is a noninvasive task that focuses on preparing the body, maintaining dignity, and basic hygiene. This task is within the scope of practice for assistive personnel.

D. Assisting with low-carbohydrate diet selections: Assisting with dietary teaching or making food choices involves clinical guidance and education, which must be performed by a licensed nurse or dietitian rather than an assistive personnel.

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Correct Answer is A

Explanation

Rationale:

A. The child believes the person will return: Preschoolers view death as temporary and reversible due to their developmental stage and limited understanding of permanence. Magical thinking often leads them to expect the deceased person to come back.

B. The child focuses on his own mortality: This is more typical of older school-age children or adolescents, who have a more developed understanding of death’s permanence and may begin to consider their own vulnerability.

C. The child refuses to talk about the death: Avoidance can occur at any age, but it is not the primary expected response in preschoolers. At this stage, they may ask repetitive questions or make statements that suggest misunderstanding, rather than complete refusal to talk.

D. The child expresses curiosity about the death process: Curiosity about death’s physical aspects is more common in school-age children, who have greater cognitive ability to think concretely about biological processes.

A. Assess the client's breath sounds. B. Restrict the client's fluid intake. C. Perform chest percussion and vibration. D. Increase oxygen flow rate to 4 L/min. E. Instruct the client to perform diaphragmatic breathing. F. Place the client in a supine position.

Correct Answer is ["A","C","E"]

Explanation

A. Assess the client’s breath sounds: Auscultation helps determine how well interventions like albuterol and oxygen are working. Detecting changes such as worsening wheezes, crackles, or diminished sounds ensures early recognition of complications. This is vital given the client’s chronic smoking history and respiratory distress.

B. Restrict the client’s fluid intake: Adequate hydration thins mucus, making it easier to clear. Unless there is heart or kidney failure, fluids should be encouraged. Restricting intake could worsen secretion retention and impair gas exchange.

C. Perform chest percussion and vibration: These techniques loosen mucus and promote clearance in clients with COPD or chronic bronchitis. Because the client has a productive cough and abnormal lung sounds, this intervention supports better airway patency. It also works well alongside bronchodilators for improved breathing.

D. Increase oxygen flow rate to 4 L/min: In clients with chronic CO₂ retention, too much oxygen can suppress respiratory drive. The current prescription of 2 L/min should be maintained unless the provider reassesses and orders changes based on ABGs.

E. Instruct the client to perform diaphragmatic breathing: This method enhances airflow to the lower lungs, reduces accessory muscle use, and improves oxygen exchange. For a COPD client, it helps conserve energy and improve ventilation. Combined with pursed-lip breathing, it strengthens respiratory efficiency.

F. Place the client in a supine position: Lying flat limits lung expansion and can worsen dyspnea in clients with lung disease. An upright or high-Fowler’s position promotes maximal ventilation and better oxygenation.

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A nurse on a medical-surgical unit is delegating tasks to an assistive personnel (AP). Which of the following client care tasks is within the scope of practice for the AP?

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