A charge nurse is delegating tasks for a group of clients on a medical surgical unit. Which of the following tasks should the nurse delegate to the assistive personnel?
Educate a client about the purpose of a sputum specimen.
Perform irrigation of an indwelling urinary catheter.
Administer liquid aspirin to a client who is crying.
Provide a bed bath for a client who requires isolation precautions.
The Correct Answer is D
A. Educate a client about the purpose of a sputum specimen: Client education requires nursing knowledge and judgment to explain procedures, answer questions, and evaluate understanding. This cannot be delegated to assistive personnel.
B. Perform irrigation of an indwelling urinary catheter: Catheter irrigation is a sterile invasive procedure that requires nursing skill to prevent infection and complications. It falls outside the scope of assistive personnel.
C. Administer liquid aspirin to a client who is crying: Medication administration involves assessment, calculation, and monitoring for adverse effects, which are responsibilities of a licensed nurse. Assistive personnel cannot administer medications.
D. Provide a bed bath for a client who requires isolation precautions: Assisting with hygiene is within the scope of assistive personnel. They can safely provide a bed bath while following isolation protocols under the supervision of the nurse.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"B":{"answers":"B,C"},"D":{"answers":"C"},"E":{"answers":"A,C"}}
Explanation
- Temperature: A temperature of 37.4°C is within normal limits and does not specifically support any of the three conditions. While low-grade fever may be seen in appendicitis or Crohn’s flares, the absence of fever at this time limits its diagnostic value in this case.
- Vomiting: Vomiting in intussusception is common and often non-bilious in early stages, aligning with the child's light-colored emesis. Vomiting also occurs in appendicitis, especially in the early stages. However, it is not a prominent or early symptom of Crohn’s disease unless obstruction is present.
- Pain rating: Severe, intermittent abdominal pain where the child draws their knees to the chest and then returns to normal behavior is a classic symptom of intussusception. Neither Crohn’s disease nor appendicitis typically presents with this pattern, appendicitis pain is usually constant and worsening, while Crohn’s pain is chronic and non-episodic.
- Abdominal findings: A distended abdomen with hypoactive bowel sounds and a palpable sausage-shaped mass in the right upper quadrant is highly indicative of intussusception. These findings are not characteristic of appendicitis, which usually involves RLQ pain, or Crohn’s, which rarely presents with a discrete palpable mass.
- Stool: The presence of blood and mucus in the stool ("currant jelly stool") is strongly associated with intussusception and may also occur in Crohn’s disease during flares due to colonic inflammation. Appendicitis does not typically cause bloody or mucoid stools, making this finding inconsistent with that diagnosis.
Correct Answer is A
Explanation
A. Instill erythromycin ointment into the newborn's eyes: Erythromycin ophthalmic ointment is routinely applied to all newborns to prevent ophthalmia neonatorum, a serious eye infection caused by exposure to Neisseria gonorrhoeae during birth.
B. Give oral sulfadiazine to the mother prior to delivery: Sulfonamides are not recommended for gonorrhea treatment in laboring clients and are ineffective in preventing neonatal eye infections.
C. Administer penicillin G procaine IM to the newborn: Penicillin is used to treat confirmed neonatal infections, not as a routine prophylaxis against gonococcal eye infections.
D. Apply miconazole vaginal cream to the mother prior to delivery: Miconazole is an antifungal used for vaginal yeast infections and has no effect on gonorrhea, so it is not indicated for preventing neonatal infection.
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