36: A nurse is delegating care for a group of four clients. Which of the following tasks should the nurse delegate to an assistive person?
Irrigate and perform a dressing change for a client who has a pressure injury wound.
Obtain a daily weight on a client who has heart failure.
Teach the use of an incentive spirometer to a postoperative client.
Administer oral PRN pain medication to a client who has arthritis.
The Correct Answer is B
A. Irrigate and perform a dressing change for a client who has a pressure injury wound: This task requires specialized knowledge and skill, particularly in wound care management. It involves assessing the wound, choosing appropriate dressings, and monitoring for signs of infection, which are beyond the scope of duties for assistive personnel.
B. Obtain a daily weight on a client who has heart failure: This task is suitable for delegation to an assistive person because it is a routine, non-invasive procedure that does not require clinical judgment or assessment. It helps in monitoring the client's condition, especially in heart failure management.
C. Teach the use of an incentive spirometer to a postoperative client: Teaching involves educating the client on the proper technique and benefits of using the device, which requires nursing judgment and the ability to address questions or concerns. This task should be performed by a nurse.
D. Administer oral PRN pain medication to a client who has arthritis: Administering medications involves evaluating the client’s pain level, assessing potential side effects, and ensuring the correct medication is given, which requires a nurse’s clinical judgment and knowledge.
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Related Questions
Correct Answer is C
Explanation
A. Place the chair at a 90° angle to the bed: Incorrect. The chair should be placed at an angle to facilitate a smoother transfer, usually around 45° to the bed, allowing easier movement from the bed to the chair.
B. Place the chair on the client's left side: Incorrect. The chair should be positioned on the strong side of the client if possible, or the side the client will be transferring towards, not necessarily the left side.
C. Lock the wheels on the client's bed: Correct. Locking the wheels on the bed ensures that the bed remains stationary during the transfer, providing safety and stability for the client.
D. Raise the height of the client's bed: Incorrect. The bed should be adjusted to a height that allows the nurse to safely transfer the client without excessive bending or stretching. However, raising it too high might make it difficult for the nurse to maneuver the client safely.
Correct Answer is D
Explanation
A. Episodic acute stress: This term is not commonly used in clinical practice and does not accurately describe the condition associated with recurring flashbacks of a past traumatic event.
B. Irritable bowel syndrome (IBS): IBS is a gastrointestinal disorder and is not related to the psychological symptoms described, such as flashbacks of traumatic events.
C. Acute stress disorder (ASD): ASD occurs within the first month after a traumatic event and involves symptoms like flashbacks, but since the traumatic event occurred a year ago, it is more consistent with PTSD.
D. Posttraumatic stress disorder (PTSD): PTSD is characterized by persistent symptoms such as flashbacks, intrusive memories, and severe anxiety that occur long after the traumatic event, fitting the client's reported symptoms.
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