A nurse on a medical-surgical unit is planning care for four clients. Which of the following tasks should the nurse delegate to an assistive personnel (AP)?

Administering a rectal suppository for a client who has postoperative constipation.

Instructing a postoperative client to use an incentive spirometer.

Measuring blood glucose using a monitor for a client who has diabetic ketoacidosis.

Using a pulse oximeter to measure oxygen saturation for a client who is ready for discharge.

Answer and Explanation

The Correct Answer is D

Choice A rationale: Administering a rectal suppository is a medication administration task that should be performed by a licensed nurse, not delegated to an assistive personnel.

Choice B rationale: Instructing a client to use an incentive spirometer involves providing education and ensuring proper technique, which falls within the scope of practice of a licensed nurse.

Choice C rationale: Measuring blood glucose for a client with diabetic ketoacidosis involves monitoring a critical condition and interpreting results, which should be done by a licensed nurse.

Choice D rationale: Using a pulse oximeter to measure oxygen saturation is a simple and routine task that can be delegated to an assistive personnel for a stable client who is ready for discharge.

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Correct Answer is C

Explanation

Choice A rationale:

Exerting firm pressure when placing the probe (Choice A) is not recommended because it can potentially compress the blood vessels and impede blood flow. This can lead to inaccurate readings and compromise the assessment of the pedal pulses in a client with peripheral vascular disease.

Choice B rationale:

Applying the probe to the exterior aspect of the ankle (Choice B) is not the standard approach for assessing pedal pulses. The pedal pulses are typically assessed on the dorsal (top) and posterior (back) aspects of the foot, as well as the lateral (side) aspects of the ankle. Placing the probe on the exterior aspect of the ankle might not yield accurate results.

Choice C rationale:

Moving the probe until a whooshing sound is present (Choice C) is the correct action when using a Doppler ultrasound stethoscope to assess pedal pulses. The whooshing sound, known as "Doppler sound," indicates the presence of blood flow. The nurse should gently maneuver the probe until this sound is heard, allowing for an accurate assessment of the pulses and blood flow status.

Choice D rationale:

Holding the probe at a 30° angle to the blood vessel (Choice D) is not a standard practice for assessing pedal pulses with a Doppler ultrasound stethoscope. The nurse should place the probe directly over the pulse site and adjust its position until the Doppler sound is detected.

A. Unclamp the client's gastrostomy tube before connecting the syringe to it. B. Verify that the client's gastric pH is at least 7 prior to feeding. C. Pour the client's formula into the syringe, raising or lowering it to control the rate of flow. D. Apply sterile gloves before accessing the client's gastrostomy tube.

Correct Answer is A

Explanation

Choice A rationale:

Unclamping the client's gastrostomy tube before connecting the syringe is the correct action. This allows the feeding to flow freely into the stomach. Clamping the tube while administering the feeding would prevent the formula from entering the stomach properly.

Choice B rationale:

Verifying the client's gastric pH to be at least 7 prior to feeding is not necessary for administering intermittent enteral feedings. Gastric pH varies widely among individuals and is not a standard requirement before every feeding.

Choice C rationale:

Pouring the client's formula into the syringe and adjusting the syringe's height to control the rate of flow is not recommended. Controlling the rate of flow in this manner is imprecise and can lead to inconsistent delivery of the formula, potentially causing discomfort or complications.

Choice D rationale:

Applying sterile gloves before accessing the client's gastrostomy tube is an important step in infection control, but it is not specifically related to administering intermittent enteral feedings. Sterile gloves are essential to prevent contamination and infection during tube maintenance and insertion, not during the feeding process itself.

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A nurse on a medical-surgical unit is planning care for four clients. Which of the following tasks should the nurse delegate to an assistive personnel (AP)?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is using a Doppler ultrasound stethoscope to assess the pedal pulses of a client who has peripheral vascular disease. Which of the following actions should the nurse plan to take?

Correct Answer is C

Explanation

A nurse is caring for a client who is receiving intermittent enteral feedings via a gastrostomy tube. Which of the following actions should the nurse take when administering the feeding?

Correct Answer is A

Explanation

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