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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","D","E"]
Explanation
Rationale for correct choices:
- Skin turgor: Poor skin turgor indicates dehydration, which can lead to electrolyte imbalances, hypotension, and renal complications. Immediate assessment and fluid management are necessary to prevent further physiological deterioration.
- Heart rate: A heart rate of 120/min is tachycardic. This can be caused by dehydration, stimulant effects of mania, or other underlying medical issues. It requires prompt monitoring and intervention to prevent cardiovascular compromise.
- Sleep pattern: The client has not slept for 2 days, which increases the risk for physical exhaustion, worsening psychiatric symptoms, and impaired judgment. Sleep deprivation in the context of mania requires immediate attention to stabilize the client.
- Hallucinations: The client reports listening to unseen others, indicating auditory hallucinations. This can pose a risk for self-harm or unsafe behaviors, and immediate psychiatric assessment and intervention are warranted.
Rationale for incorrect choice:
- Hygiene: While the client’s hair and clothing are unclean, indicating self-care deficits, this is not an immediate threat to physiological stability. It is important for overall care planning but does not require urgent intervention compared to dehydration, tachycardia, sleep deprivation, or hallucinations.
Correct Answer is A
Explanation
A. Instill erythromycin ointment into the newborn's eyes: Erythromycin ophthalmic ointment is routinely applied to all newborns to prevent ophthalmia neonatorum, a serious eye infection caused by exposure to Neisseria gonorrhoeae during birth.
B. Give oral sulfadiazine to the mother prior to delivery: Sulfonamides are not recommended for gonorrhea treatment in laboring clients and are ineffective in preventing neonatal eye infections.
C. Administer penicillin G procaine IM to the newborn: Penicillin is used to treat confirmed neonatal infections, not as a routine prophylaxis against gonococcal eye infections.
D. Apply miconazole vaginal cream to the mother prior to delivery: Miconazole is an antifungal used for vaginal yeast infections and has no effect on gonorrhea, so it is not indicated for preventing neonatal infection.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.