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 C

Explanation

Rationale:

A. The client's lung sounds remain clear during the transfusion: Clear lung sounds indicate the absence of fluid overload or pulmonary complications, which is a safety indicator, but it does not reflect the effectiveness of the transfusion in improving oxygen-carrying capacity.

B. The client's blood pressure increases to 140/85 mm Hg following the transfusion: A sudden rise in blood pressure could indicate fluid overload or a transfusion reaction, not necessarily a positive response to the transfusion.

C. The client's hemoglobin level increases following the transfusion: An increase in hemoglobin indicates that the transfused red blood cells have effectively raised the client’s oxygen-carrying capacity, demonstrating a positive therapeutic response.

D. The client is afebrile during the transfusion: Remaining afebrile indicates the absence of a febrile transfusion reaction, which is a safety measure, but it does not show that the transfusion achieved its therapeutic goal.

A. Serum potassium B. Platelet count C. Urine ketones D. Total bilirubin

Correct Answer is A

Explanation

Rationale:

A. Serum potassium: Spironolactone is a potassium-sparing diuretic that can cause hyperkalemia. Monitoring serum potassium is essential to detect elevated levels early and prevent cardiac complications.

B. Platelet count: Spironolactone does not significantly affect platelet production or function, so routine monitoring of platelets is not indicated for this medication.

C. Urine ketones: Ketone monitoring is relevant for clients with uncontrolled diabetes or ketosis, but it is not related to spironolactone therapy.

D. Total bilirubin: Bilirubin levels are used to assess liver function, which is not directly affected by spironolactone in most clients, so routine monitoring is not necessary unless the client has underlying hepatic disease.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is A

Explanation

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