A nurse and an assistive personnel (AP) are caring for a client who requests a PRN pain medication. After the nurse administers the medication, which of the following tasks should the nurse assign to the AP?

Document the client's respiratory rate in 1 hr.

Monitor the client for an allergic reaction for 30 min.

Check the client's response to the medication in 1 hr.

Evaluate the client for therapeutic effects in 30 min.

Answer and Explanation

The Correct Answer is A

A.   Documenting the client's respiratory rate in 1 hour is within the scope of practice for an assistive personnel (AP) and does not require nursing judgment or assessment.
B.   Monitoring the client for an allergic reaction for 30 minutes requires nursing judgment and assessment skills to recognize signs and symptoms of allergic reactions.
C.   Checking the client's response to the medication in 1 hour requires nursing judgment and assessment skills to evaluate pain relief and any adverse effects.
D.   Evaluating the client for therapeutic effects in 30 minutes requires nursing judgment and assessment skills to determine the effectiveness of the pain medication.

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Correct Answer is A

Explanation

A. Administer scheduled pain medications is appropriate because providing comfort is a priority in end-of-life care. Administering scheduled pain medications helps alleviate any discomfort or pain the client may be experiencing.
B. Providing oral care every 6 hr may not be necessary in the end-of-life stage, as the client's ability to tolerate oral care may decrease, and excessive oral care may cause discomfort.
C. Administering liquids using a syringe may not be appropriate if the client is unable to swallow or if there are concerns about aspiration.
D. Whispering when talking to family members is not necessary; instead, the nurse should communicate in a calm and clear manner, adjusting the volume and tone as needed to accommodate the client's condition and preferences.

A. "Many people have colostomies and they live full lives." B. "Would it help to speak with someone else who has a colostomy?" C. "Why don't you want people to see the colostomy bag?" D. "You shouldn't worry, the colostomy is probably only temporary."

Correct Answer is A

Explanation

Correct. This response provides reassurance and normalizes the client's experience by emphasizing that having a colostomy does not prevent individuals from leading fulfilling lives. B. Incorrect. While peer support can be beneficial, this response does not directly address the client's concerns or provide immediate reassurance.
C. Incorrect. This response may put the client on the spot and make them feel uncomfortable discussing their feelings. It's important to respect the client's privacy and autonomy in disclosing their reasons for not wanting others to see the colostomy bag.
D. Incorrect. Making assumptions about the temporary nature of the colostomy without medical confirmation may not be accurate and can contribute to false hope or disappointment if the client's colostomy is permanent. It's important to provide honest and accurate information while being supportive of the client's emotional needs.

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A nurse and an assistive personnel (AP) are caring for a client who requests a PRN pain medication. After the nurse administers the medication, which of the following tasks should the nurse assign to the AP?

Nursing Test Bank

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