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 B

Explanation

Choice A rationale:

Increased sensitivity to touch is not an expected physiological change associated with aging. Older adults often experience decreased sensitivity to touch due to changes in nerve endings and decreased skin elasticity. This can lead to decreased sensation rather than increased sensitivity.

Choice B rationale:

Decreased peripheral circulation is an expected physiological change associated with aging. With age, blood vessels can become less elastic and more narrow, leading to reduced blood flow to the extremities. This can result in cold extremities, delayed wound healing, and increased vulnerability to skin breakdown. Nurses should assess for signs of impaired circulation in older adult clients and provide appropriate interventions to prevent complications.

Choice C rationale:

Decreased airway resistance is not an expected physiological change associated with aging. Older adults often experience increased airway resistance due to changes in lung elasticity and chest wall compliance. This can lead to decreased lung function and a higher risk of respiratory issues such as pneumonia and bronchitis.

Choice D rationale:

Increased appetite is not an expected physiological change associated with aging. In fact, many older adults experience a decrease in appetite due to factors such as changes in metabolism, decreased sense of taste and smell, and underlying health conditions. This reduced appetite can contribute to malnutrition and weight loss in the elderly population.

A. 30° lateral. B. Lateral semi-prone recumbent. C. Supine. D. 45° supported Fowler's.

Correct Answer is A

Explanation

The correct answer is choice A. 30° lateral.

Choice A rationale:

The 30° lateral position is recommended to reduce pressure on the client’s bony prominences. This position helps distribute the client’s weight more evenly and reduces the risk of pressure injury formation.

Choice B rationale:

The lateral semi-prone recumbent position may not be as effective in reducing pressure on bony prominences as the 30° lateral position. It could potentially increase pressure on certain areas, depending on the client’s body shape and condition.

Choice C rationale:

The supine position can increase pressure on the sacrum and heels, which are common sites for pressure injuries. Therefore, it is not the best position for a client at risk for pressure injury formation.

Choice D rationale:

The 45° supported Fowler’s position can increase pressure on the sacrum and ischial tuberosities, another common site for pressure injuries. Therefore, it is not the most effective position for reducing pressure on bony prominences for a client at risk for pressure injury formation.

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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 assessing an older adult client. Which of the following should the nurse identify as an expected physiological change associated with aging?

Correct Answer is B

Explanation

A nurse is caring for a client who is at risk for pressure injury formation due to immobility. The nurse should place the client in which of the following positions to reduce pressure on the client's bony prominences?

Correct Answer is A

Explanation

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