An assistive personnel (AP) reports to the nurse that a client who is 3 days postoperative following an abdominal hysterectomy has a dressing that is saturated with blood. Which of the following tasks should the nurse delegate to the AP?

Palpate for possible bladder distention.

Observe the incision site.

Change the abdominal dressing.

Obtain vital signs.

Answer and Explanation

The Correct Answer is D

Rationale:

A. Palpate for possible bladder distention is a task that requires nursing assessment skills and should be done by the nurse.

B. Observe the incision site is a nursing task that involves assessing for signs of complications.

C. Change the abdominal dressing requires sterile technique and should be done by a nurse to prevent infection and ensure proper care.

D. Obtain vital signs is within the AP’s scope of practice and is a task that can be delegated. It is important for monitoring the client’s status and identifying potential issues.

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Correct Answer is B

Explanation

Rationale:

A. "I am sure these feelings will pass once you go home." is dismissive and does not address the client's current emotional state.

B. "Tell me what you understand about your illness." opens up a dialogue for the client to express their feelings and concerns, which can help in assessing their emotional state and providing support.

C. "Tell me why you feel hopeless." might be too direct and could make the client feel pressured.

D. "If I were you, I would ask for a referral to hospice care." could be perceived as judgmental and does not address the client’s immediate feelings of hopelessness.

A. "The client works in the hospital radiology department." B. "The client discussed having prior thoughts of suicide." C. "The client's blood pressure and pulse have been fluctuating throughout the day." D. "The client's family members have been present most of the day."

Correct Answer is C

Explanation

A. "The client works in the hospital radiology department": This information is irrelevant to the client’s current health status and does not imply a need for total care by the nurse.

B. "The client discussed having prior thoughts of suicide": While suicidal ideation is serious and requires careful monitoring and assessment, this information alone does not necessarily indicate that the nurse must assume total care. A nurse would still delegate non-critical tasks to the AP, but constant monitoring and appropriate interventions would still be the nurse’s responsibility.

C. "The client's blood pressure and pulse have been fluctuating throughout the day": Fluctuating vital signs, especially blood pressure and pulse, can indicate an unstable condition that may require immediate attention and careful monitoring. This scenario suggests that the client’s condition may be critical and requires ongoing assessment and evaluation by the nurse, rather than simply delegating tasks like monitoring vital signs to assistive personnel (AP). The nurse needs to assess the situation thoroughly, interpret the fluctuations, and adjust the care plan accordingly.

D. "The client's family members have been present most of the day": Family presence alone does not impact the need for total care by the nurse. It is important for the nurse to communicate with the family, but this statement does not indicate the need for the nurse to assume total care over other team members.

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An assistive personnel (AP) reports to the nurse that a client who is 3 days postoperative following an abdominal hysterectomy has a dressing that is saturated with blood. Which of the following tasks should the nurse delegate to the AP?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client who is terminally ill tells a nurse on the medical-surgical unit that she feels hopeless. Which of the following statements by the nurse is appropriate?

Correct Answer is B

Explanation

A nurse is receiving change-of-shift report at the start of the shift. Which of the following statements by the nurse giving report indicates to the oncoming nurse that she should assume total care for the client, rather than assigning tasks to the assistive personnel (AP)?

Correct Answer is C

Explanation

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