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

Answer and Explanation

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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Correct Answer is B

Explanation

A. A client who reports experiencing short-term memory loss:

Memory loss is a common issue in older adults and does not necessarily indicate elder abuse. While it is a concern that should be addressed, it may not be related to abuse unless there are specific circumstances suggesting mistreatment.

B. A client who is wearing urine-scented clothing.

Wearing urine-scented clothing can be indicative of neglect, which is a form of elder abuse. Neglect occurs when the basic needs of an older adult, such as hygiene and cleanliness, are not adequately met. The nurse should report this finding to the case manager so that appropriate interventions and assessments can be made to address the potential abuse or neglect.

C. A client who has fingernails that are discolored and broken:

Fingernail issues can have various causes, including medical conditions or self-neglect. Discolored and broken fingernails alone may not be conclusive evidence of elder abuse, and further assessment is needed to determine the cause.

D. A client who provides a detailed description of a recent fall at home:

While falls are a concern, providing a detailed description of a fall is not necessarily indicative of elder abuse. Falls can occur for various reasons, and additional assessment is needed to determine the circumstances surrounding the fall and whether abuse or neglect is involved.

Correct Answer is ["0.5"]

Explanation

To calculate the volume (mL) that the nurse should administer, you can use the following formula:

Volume (mL) = Dose (mg)/Concentration (mg/mL)

In this case:

Volume =25 mg/50 mg/mL
Volume=0.5mL

Therefore, the nurse should administer 0.5 mL of promethazine for the 25 mg IM dose, rounded to the nearest tenth.

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A nurse on a medical unit is making staff assignments. Which of the following tasks should the nurse delegate to an assistive personnel?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A home health nurse is caring for a group of older adult clients. The nurse should report which of the following clients to the case manager for findings consistent with elder abuse?

Correct Answer is B

Explanation

A nurse is preparing to administer promethazine 25 mg IM to a client. Available is promethazine 50 mg/mL. How many mL should the nurse administer? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)

Correct Answer is ["0.5"]

Explanation

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