A nurse on a medical-surgical unit is teaching a newly licensed nurse about tasks to delegate to assistive personnel (AP). Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?
"An AP may monitor the peripheral IV insertion site of a client who is receiving replacement fluids."
"An AP may count the respirations of a client who is going to have surgery later the same day."
"An AP may take orthostatic blood pressure measurements from a client who reports dizziness."
"An AP may perform a central line dressing change for a client who is ready for discharge."
The Correct Answer is B
A. "An AP may monitor the peripheral IV insertion site of a client who is receiving replacement fluids." –
Monitoring IV sites requires assessment skills and clinical judgment, which are within the scope of a licensed nurse, not assistive personnel.
B. "An AP may count the respirations of a client who is going to have surgery later the same day." –
Counting respirations is a basic task within the AP’s scope of practice. However, the nurse is responsible for interpreting the findings.
C. "An AP may take orthostatic blood pressure measurements from a client who reports dizziness." –
Measuring orthostatic blood pressure requires critical thinking and assessment of the client’s condition, which falls under the nurse’s responsibilities.
D. "An AP may perform a central line dressing change for a client who is ready for discharge." –
Performing a central line dressing change is a sterile procedure that requires nursing assessment and should be completed by a licensed nurse.
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Related Questions
Correct Answer is C
Explanation
A. "Remove clocks from the client's room." –
Removing clocks can increase confusion and disorientation. Instead, having a visible clock and calendar can help the client stay oriented.
B. "Check on the client frequently while he is in the restroom." –
While frequent monitoring is important, excessive surveillance may increase agitation and distress. A better alternative is to ensure the restroom is safe and accessible.
C. "Encourage physical activity throughout the day to expend energy." –
Engaging the client in physical activity helps reduce restlessness, promotes better sleep, and decreases the likelihood of agitation, which can reduce the need for restraints.
D. "Use full-length side rails on the client's bed." –
Full-length side rails can be considered a form of restraint as they may limit movement and increase the risk of falls or injury if the client tries to climb over them.
Correct Answer is D
Explanation
A. "Insert the IV catheter using the Z-track technique." The Z-track technique is used for intramuscular (IM) injections, not IV therapy.
B. "Insert the IV catheter with the bevel down." The bevel should be up to facilitate smooth vein entry.
C. "Remove the roller clamp from the tubing prior to IV insertion." The roller clamp should remain in place to control fluid flow and prevent air from entering the tubing.
D. "Apply the tourniquet 5 to 10 cm (about 2 to 4 in) above the IV insertion site." This placement helps distend the vein for easier cannulation without restricting arterial blood flow.
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