The following 4 questions pertain to this case study:
Which task is appropriate for the nurse to delegate to experienced certified nurse assistant (CNA)?
Monitor for shortness of breath or fatigue after ambulation.
Determine whether the patient is ready to increase activity.
Obtain the patient’s blood pressure and pulse rate after ambulation.
Instruct the patient on how to use an incentive spirometer.
The Correct Answer is C
Choice A reason:
Monitoring for shortness of breath or fatigue after ambulation is a critical task that requires clinical judgment and assessment skills. Certified Nurse Assistants (CNAs) are trained to assist with basic patient care activities but are not typically trained to assess and interpret clinical symptoms such as shortness of breath or fatigue. These symptoms could indicate serious complications such as pulmonary embolism or cardiac issues, which require immediate attention from a licensed nurse or physician. Therefore, this task is not appropriate for delegation to a CNA.
Choice B reason:
Determining whether the patient is ready to increase activity involves assessing the patient’s overall condition, including their vital signs, pain levels, and physical capabilities. This requires a comprehensive understanding of the patient’s medical history and current status, which falls within the scope of practice of a registered nurse (RN) or licensed practical nurse (LPN). CNAs do not have the training to make such determinations, as it involves critical thinking and clinical decision-making skills. Therefore, this task should not be delegated to a CNA.
Choice C reason:
Obtaining the patient’s blood pressure and pulse rate after ambulation is a task that is appropriate for delegation to a CNA. CNAs are trained to measure and record vital signs, including blood pressure and pulse rate. This task does not require clinical judgment or decision-making, making it suitable for delegation. The CNA can report the findings to the nurse, who can then interpret the results and make any necessary clinical decisions. This delegation allows the nurse to focus on more complex tasks that require their advanced training and expertise.
Choice D reason:
Instructing the patient on how to use an incentive spirometer involves patient education, which is a responsibility that typically falls to licensed nurses. Proper use of an incentive spirometer is crucial for preventing postoperative complications such as atelectasis and pneumonia. Ensuring that the patient understands how to use the device correctly requires not only demonstrating its use but also assessing the patient’s comprehension and ability to perform the task. This level of patient education and assessment is beyond the scope of practice for a CNA.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C","E"]
Explanation
Choice A: Properly cleaning all reusable equipment once each day
While cleaning reusable equipment is important, it should be done after each use, not just once a day. This ensures that any potential pathogens are removed before the equipment is used on another patient, thereby preventing cross-contamination.
Choice B: Appropriately using PPE
This is a correct answer. Personal Protective Equipment (PPE) such as gloves, masks, gowns, and eye protection are essential in preventing the spread of infection. Proper use of PPE helps protect both healthcare workers and patients from exposure to infectious agents.
Choice C: Ensuring all environmental surfaces are properly cleaned, disinfected, and maintained
This is another correct answer. Regular cleaning and disinfection of environmental surfaces, such as bed rails, doorknobs, and medical equipment, are crucial in preventing the spread of infections. Maintaining a clean environment reduces the risk of healthcare-associated infections.
Choice D: Avoiding all invasive interventions
Avoiding invasive interventions is not a practical or realistic approach to preventing infections. While minimizing unnecessary invasive procedures can reduce infection risk, many invasive interventions are necessary for patient care. Instead, proper aseptic techniques should be used during these procedures to prevent infections.
Choice E: Performing hand washing or using an alcohol-based hand sanitizer before and after patient contact or procedures
This is also a correct answer. Hand hygiene is one of the most effective measures to prevent the spread of infections. Washing hands with soap and water or using an alcohol-based hand sanitizer before and after patient contact or procedures significantly reduces the transmission of pathogens.
Correct Answer is ["B","C","E","F","H"]
Explanation
Choice A: Agency policy
While agency policy provides guidelines for reassessment intervals, it is not the primary factor in determining the specific time frame for reassessing a patient’s pain level. Policies serve as a general framework, but individual patient needs and clinical judgment should guide the reassessment timing.
Choice B: Type of intervention
This is a correct answer. The type of pain management intervention used significantly influences the reassessment time frame. For example, after administering intravenous pain medication, reassessment should occur sooner compared to oral medications due to the faster onset of action. Different interventions have varying durations of effectiveness, necessitating tailored reassessment intervals.
Choice C: Pain severity
This is another correct answer. The severity of the patient’s pain is a crucial factor in determining reassessment timing. Patients experiencing severe pain may require more frequent reassessments to ensure that pain management strategies are effective and to make timely adjustments if needed.
Choice D: If family members are present in the patient’s room
The presence of family members in the patient’s room is not a primary factor in determining the reassessment time frame. While family members can provide valuable support and information, the focus should remain on the patient’s clinical needs and the effectiveness of pain management interventions.
Choice E: The patient’s psychosocial condition
This is a correct answer. The patient’s psychosocial condition, including their emotional and mental state, can impact their perception of pain and response to pain management. Patients with anxiety, depression, or other psychosocial issues may require more frequent reassessments to address both physical and emotional aspects of pain.
Choice F: Risks for adverse effects
This is also a correct answer. The potential for adverse effects from pain management interventions necessitates careful monitoring and timely reassessment. For instance, opioids carry risks of respiratory depression and sedation, requiring close observation and frequent reassessment to ensure patient safety.
Choice G: Workload of the nurse
While the nurse’s workload can influence the practical aspects of care delivery, it should not dictate the reassessment time frame. Patient needs and clinical priorities should guide reassessment intervals, with workload management being a secondary consideration.
Choice H: The patient’s physical condition
This is the final correct answer. The patient’s overall physical condition, including comorbidities and current health status, affects their response to pain management and the need for reassessment. Patients with complex medical conditions may require more frequent monitoring to ensure effective pain control and to promptly address any complications.
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