A nurse on a medical unit is making staff assignments. Which of the following tasks should the nurse delegate to an assistive personnel?
Inserting a straight urinary catheter for a client
Performing perineal care for a client who has an indwelling urinary catheter
Showing a client how to use an incentive spirometer
Increasing oxygen flow for a client who has a nasal cannula
The Correct Answer is B
A. Inserting a straight urinary catheter for a client:
Inserting a urinary catheter involves a sterile procedure and requires the specialized skills of a licensed nurse. This task should not be delegated to assistive personnel.
B. Performing perineal care for a client who has an indwelling urinary catheter.
Delegating tasks should align with the education, training, and scope of practice of the assistive personnel. Performing perineal care for a client with an indwelling urinary catheter is a task that can be appropriately delegated to assistive personnel. This task involves basic hygiene and does not require the advanced skills or knowledge of a licensed nurse.
C. Showing a client how to use an incentive spirometer:
Educational tasks, such as demonstrating how to use an incentive spirometer, require knowledge and understanding of the device, as well as the ability to assess and respond to the client's needs. This task is best performed by a licensed nurse.
D. Increasing oxygen flow for a client who has a nasal cannula:
Adjusting oxygen flow involves assessing the client's condition and making decisions based on the client's oxygenation needs. This task requires the clinical judgment of a licensed nurse and should not be delegated to assistive personnel.
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Related Questions
Correct Answer is B
Explanation
A. Flush the tube with 5 mL of water:
Explanation: Flushing the tube with water is a routine practice before and after administering medications or feedings to maintain tube patency. However, it is not the primary action to confirm tube placement.
B. Test the pH of fluid aspirated from the tube (Correct Answer):
Explanation: Testing the pH of aspirated fluid helps confirm that the tube is in the stomach. A pH between 1 and 5 is generally indicative of gastric placement.
C. Inject air through the tubing and auscultate for gurgling sounds:
Explanation: This method is an older practice and is not recommended as a reliable method for verifying tube placement. Testing the pH is a more accurate and preferred method.
D. Change the bag and tubing system every 12 hr:
Explanation: Changing the bag and tubing system every 12 hours is a routine practice to maintain the integrity of the enteral feeding system. However, it is not specifically related to the initial steps in verifying tube placement.
Correct Answer is ["3ml"]
Explanation
To calculate the volume (mL) that the nurse should administer, we can follow these steps:
Convert the weight from pounds to kilograms.
1 lb = 0.453592 kg
165 lb×0.453592 kg/lb≈74.843 kg
Calculate the total dose using the weight and prescribed dose:
Total Dose (units)=Dose per kg×Weight (kg)
Total Dose=8 units/kg×74.843 kg≈598.744 units
Determine the volume using the concentration of the available solution:
Volume (mL)=Total Dose (units)/Concentration (units/mL)
Volume =598.744 units/200 units/mL ≈ 2.994 mL
Therefore, the nurse should administer approximately 3 mL of calcitonin for the 8 units/kg IM dose, rounded to the nearest whole number.
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