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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"A"}
Explanation
Provide continuous monitoring of this client: Continuous monitoring is essential to ensure the client's safety while in seclusion, particularly given their agitated and potentially harmful behavior.
Obtain provider prescription for seclusion or restraints: It's necessary to ensure that the use of seclusion is appropriately authorized and documented, following the facility's protocol and legal requirements.
Correct Answer is B
Explanation
Rationale:
A. A client who was administered erythromycin for acute glomerulonephritis and reports reddish-brown urinary output requires assessment for possible drug reaction or hematuria, but this may not be immediately life-threatening compared to hypoglycemia.
B. A client who was administered glipizide for type 2 diabetes mellitus and has a blood glucose of 68 mg/dL is at risk for hypoglycemia, which requires prompt assessment and intervention to prevent severe complications.
C. A client who was administered adalimumab for Crohn's disease, has a serum calcium level of 10 mg/dL, and reports a headache should be assessed, but the calcium level and headache are less urgent compared to immediate treatment needs for hypoglycemia.
D. A client who was administered acyclovir for cellulitis reports pain in the affected leg may require assessment for infection or medication side effects, but this is less critical than addressing hypoglycemia.
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