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 A

Choice A rationale:

Delegating the task of administering a rectal suppository to an assistive personnel (AP) is appropriate because it falls within their scope of practice and does not require advanced nursing knowledge. The administration of a rectal suppository is a routine procedure that does not involve complex assessment or critical thinking. Assistive personnel are trained to perform tasks that are repetitive and do not involve making clinical judgments.

Choice B rationale:

Instructing a postoperative client to use an incentive spirometer is a nursing intervention that requires providing education and assessing the client's understanding. The nurse should directly perform this task to ensure proper technique and address any questions or concerns the client might have. This task involves patient education and therapeutic communication, making it more appropriate for the nurse.

Choice C rationale:

Measuring blood glucose using a monitor for a client who has diabetic ketoacidosis involves collecting clinical data that requires interpretation and immediate action based on the client's condition. Diabetic ketoacidosis is a serious complication that demands timely and accurate monitoring, so the nurse should perform this task to ensure correct interpretation of the results and prompt intervention if necessary.

Choice D rationale:

Using a pulse oximeter to measure oxygen saturation for a client who is ready for discharge involves assessing the client's respiratory status and determining their readiness for discharge. This task requires clinical judgment and the ability to interpret the results within the context of the client's overall condition. The nurse should perform this task to ensure that the client is safe to be discharged.

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Correct Answer is A

Explanation

Choice A rationale:

Teaching the most crucial content early in the session is an effective strategy to engage learners and ensure that they receive essential information. This approach captures their attention and provides a solid foundation for the rest of the session. It helps establish relevance and interest, keeping the learners engaged throughout the educational program.

Choice B rationale:

Assuming that learners have no prior knowledge of first aid might not be the best approach. Adult learners often come with varying levels of knowledge and experience. It's important to assess the learners' prior knowledge and adjust the content accordingly to avoid redundancy or information that is too basic for them.

Choice C rationale:

Repetition of procedures and techniques is a valuable teaching strategy. Repetition aids in retention and comprehension. Reiterating important points reinforces learning and helps participants remember critical steps in first aid procedures. Avoiding repetition can lead to incomplete understanding and retention.

Choice D rationale:

Dividing the planned program into several sessions held about 1 week apart might not be the most effective strategy for community education. Spacing the sessions too far apart could result in learners forgetting the content or losing interest. It's better to maintain a consistent schedule to ensure continuity and engagement.

A. MSO4 4 mg IV bolus daily before dressing changes and dilute with 5 cc of water. B. Morphine 4 mg IV bolus daily at 0900 before dressing changes, dilute medication with 5 mL of sterile water. C. Morphine 4 mg IV bolus Q.D. before dressing changes and dilute with 5 cc of sterile water. D. MSO4 4 mg IV bolus daily @9 AM, dilute with 5 mL of sterile water.

Correct Answer is B

Explanation

Choice A rationale:

While the abbreviation "MSO4" represents morphine sulfate, it is safer to spell out the medication name to prevent misinterpretation. Also, the use of "cc" for volume and lack of clarity in timing make this option less desirable.

Choice B rationale:

(Correct Choice) This option correctly identifies the medication, includes the dose (4 mg), specifies the route (IV), indicates the timing (daily at 0900 before dressing changes), and provides instructions for dilution (5 mL of sterile water).

Choice C rationale:

Using "Q.D." is an abbreviation for "every day" and might lead to confusion due to unfamiliarity. Additionally, using "cc" instead of "mL" and lack of clarity in timing reduce the accuracy of this transcription.

Choice D rationale:

Using "MSO4" and "cc" are potential sources of confusion. Also, the abbreviation "@9 AM" might not be universally understood, and "mL" is a more appropriate unit for volume.

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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

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Correct Answer is A

Explanation

Correct Answer is B

Explanation

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