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 A

Explanation

To calculate how many milliliters (mL) of diazepam oral solution should be administered, you can use the following formula:

Dose (mL) = Desired dose (mg) / Concentration (mg/mL)

In this case, the desired dose is 2 mg, and the concentration of the diazepam oral solution is 5 mg/1 mL.

Dose (mL) = 2 mg / 5 mg/mL = 0.4 mL

So, the nurse should administer 0.4 mL of diazepam oral solution with each dose. The correct answer is:

A) 0.4 mL.

A. Apply the skin sealant on damp skin. B. Remove the appliance before emptying the pouch. C. Ensure that the skin is slightly damp for better adhesion of the pouch. D. Trace the size of stoma onto the skin barrier.

Correct Answer is D

Explanation

Choice A rationale:

Apply the skin sealant on damp skin. Rationale: Applying skin sealant on damp skin is not the recommended approach for securing an ostomy appliance. It's important to ensure that the skin is clean and dry before applying the sealant or the skin barrier. Moisture can compromise adhesion and lead to skin irritation or appliance detachment.

Choice B rationale:

Remove the appliance before emptying the pouch. Rationale: Removing the appliance before emptying the pouch is not a necessary step when changing an ostomy appliance. Typically, the pouch can be emptied without removing the entire appliance, which helps maintain the seal and reduces unnecessary skin exposure.

Choice C rationale:

Ensure that the skin is slightly damp for better adhesion of the pouch. Rationale: Ensuring that the skin is slightly damp is not advisable for better adhesion of the pouch. The skin should be completely dry before applying the pouch to ensure proper adhesion. Moisture on the skin can lead to leakage or detachment of the appliance.

Choice D rationale:

Trace the size of stoma onto the skin barrier. Rationale: This choice is the correct answer because tracing the size of the stoma onto the skin barrier ensures a precise fit, which is crucial for preventing leaks and maintaining the integrity of the ostomy. A proper fit also helps in preventing skin irritation and discomfort. Choosing the correct barrier size based on the stoma's dimensions is a key aspect of effective ostomy care.

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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 preparing to administer diazepam 2 mg twice daily via NG tube. Available is diazepam oral solution 5 mg/1 mL. How many mL should the nurse administer with each dose?

Correct Answer is A

Explanation

A nurse is providing teaching to a client who has a new colostomy. Which of the following actions should the nurse take when demonstrating how to change the ostomy appliance?

Correct Answer is D

Explanation

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