A nurse on a pediatric unit is working with an assistive personnel (AP). Which of the following tasks should the nurse have the AP perform first?

Feed a school-age client who has burns on both upper extremities.

Collect a stool sample for ova and parasites from a toddler.

Bathe an adolescent client who is disabled.

Ambulate a preschooler who is postoperative to the playroom.

Answer and Explanation

The Correct Answer is A

The nurse should have the AP perform the task of feeding a school-age client who has burns on both upper extremities first. This task is a high priority because it addresses the client's immediate need for nutrition and hydration. The client's burns may make it difficult for them to feed themselves, so the assistance of the AP is necessary to ensure that the client receives adequate nourishment.

The other tasks are also important, but they are not the highest priority in this situation. Collecting a stool sample for ova and parasites from a toddler [b] and bathing an adolescent client who is disabled [c] are routine tasks that can be performed as time permits. Ambulating a preschooler who is postoperative to the playroom [d] is also important for promoting mobility and recovery, but it is not as urgent as addressing the immediate need for nutrition and hydration.

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Correct Answer is A

Explanation

Assistive personnel (AP), also known as unlicensed assistive personnel (UAP), can perform tasks such as recording vital signs ¹. Collecting intake and output [a] is a task that can be delegated to an AP.

The other options are not tasks that should be delegated to an AP.

Evaluating pain relief after administering pain medication [b] involves assessing the eﬀectiveness of a medical intervention, which is typically the responsibility of a licensed nurse.

Providing a central line dressing change [c] is a complex task that requires specialized knowledge and skills.

Selecting a menu for a low-sodium diet [d] involves dietary planning, which is typically the responsibility of a licensed nurse or a registered dietitian.

A. A client who had a blood transfusion and has a blood pressure of 138/76 mm Hg. B. A client who has skeletal traction for a femur fracture and reports incisional discomfort of 4 on a scale of 0 to 10. C. A client who is 4 hours postoperative following a total hip arthroplasty and has a urinary output of 15 ml/hr

Correct Answer is C

Explanation

The correct answer is Choice C.

Choice A rationale: A client who had a blood transfusion and has a blood pressure of 138/76 mm Hg. This client is stable. The blood pressure is within normal range, indicating that the client is not experiencing a transfusion reaction, which could cause hypotension. Therefore, this client is not the highest priority.

Choice B rationale: A client who has skeletal traction for a femur fracture and reports incisional discomfort of 4 on a scale of 0 to 10. While pain management is an important aspect of client care, a pain level of 4 indicates that the client’s pain is manageable. Therefore, this client is not the highest priority.

Choice C rationale: A client who is 4 hours postoperative following a total hip arthroplasty and has a urinary output of 15 mL/hr. This client is showing signs of oliguria, which could indicate a serious complication such as hypovolemia or acute kidney injury. This client is the highest priority because these complications can lead to further serious issues such as shock or end-organ damage if not addressed promptly.

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A nurse on a pediatric unit is working with an assistive personnel (AP). Which of the following tasks should the nurse have the AP perform first?

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Naxlex Comprehensive Predictor Exams

A nurse is delegating client care assignments for the upcoming shift. Which of the following tasks should the nurse plan to delegate to the assistive personnel (AP)?

Correct Answer is A

Explanation

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Correct Answer is C

Explanation

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