A charge nurse is making shift assignments on a medical-surgical unit. Which of the following tasks should the nurse assign to the AP?
Measuring oxygen saturation for a client who has dyspnea
Performing nasal hygiene for a client who has an NG tube
Pouching a client's ostomy bag for a new colostomy
Inserting a rectal suppository for a client who is vomiting
The Correct Answer is C
a. Measuring oxygen saturation requires nursing judgment and assessment skills, which are beyond the scope of practice for an assistive personnel (AP).
b. Nasal hygiene for a client with an NG tube involves specific skills and requires nursing assessment to ensure proper technique and patient comfort.
c. Pouching a client's ostomy bag involves routine care that can be safely performed by assistive personnel under the direction and supervision of a nurse.
d. Inserting a rectal suppository requires nursing judgment and assessment to determine appropriateness based on the client's condition, which is beyond the scope of practice for an AP.
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Related Questions
Correct Answer is B
Explanation
a. Rotavirus infections are typically reported to local health departments, but they are not generally considered reportable diseases to state health departments.
b. Pertussis, also known as whooping cough, is a reportable disease in most jurisdictions due to its contagious nature and potential for outbreaks.
c. Respiratory syncytial virus (RSV) infections are not usually reportable to state health departments unless they are part of a larger outbreak or cluster of cases.
d. Group B streptococcus (GBS) infections, while significant in certain populations such as newborns, are not typically reportable diseases to state health departments.
Correct Answer is D
Explanation
a. Review the chart for nonrestraint alternatives for agitation: While reviewing alternatives is important, the immediate concern is ensuring the safety and well-being of the client by removing the restraints.
b. Inform the unit manager: While it's important to inform the unit manager, the first action should be to address the immediate safety issue by removing the restraints.
c. Speak with the AP about the incident: While it's important to discuss the incident with the assistive personnel, the first priority is to remove the restraints to prevent harm to the client.
d. Remove the restraints from the client’s wrist: This is the correct action to take first to ensure the client's safety and prevent further harm. Afterward, the nurse can address the situation with the assistive personnel and review alternatives for managing the client's agitation.
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