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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
During bladder irrigation, the nurse should instill a specific volume of the prescribed irrigation solution into the bladder to facilitate the removal of clots, mucus, or other debris from the urinary catheter and bladder. The recommended volume to instill is usually 400 to 500 mL, which helps to effectively flush out the bladder without overdistending it.
Choice B rationale:
Clamping the drainage tubing distal to the injection port during bladder irrigation is incorrect. The drainage tubing should remain unclamped to allow the irrigation solution to flow into the bladder and facilitate the removal of debris. Clamping the tubing would prevent the solution from entering the bladder and hinder the irrigation process.
Choice C rationale:
Using a syringe with a 19-gauge needle is not relevant to the process of bladder irrigation. Bladder irrigation is typically performed using a specific irrigation kit that includes appropriate tubing and components, not a syringe and needle.
Choice D rationale:
Withdrawing the irrigation solution into the syringe is not a standard procedure during bladder irrigation. The purpose of bladder irrigation is to instill a specific volume of solution into the bladder and then allow it to drain out, flushing the bladder in the process. Drawing the solution back into a syringe after instillation would disrupt the intended irrigation process.
Correct Answer is C
Explanation
The correct answer is choice c. List of community resources.
Choice A rationale:
Emergency contact information is typically found in the patient’s admission records or demographic section, not in the discharge summary.
Choice B rationale:
Intake and output summary is part of the daily nursing notes or fluid balance chart, not usually included in the discharge summary.
Choice C rationale:
The discharge summary often includes a list of community resources to support the patient after discharge, such as contact information for follow-up care, support groups, or home health services.
Choice D rationale:
Basic demographic data is recorded in the patient’s initial admission records and is not typically repeated in the discharge summary.
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