A nurse is assigning tasks to an assistive personnel (AP). Which of the following tasks should the nurse assign to the AP?

Change a dressing on an implanted central venous access device.

Remove an NG tube.

Suction a new tracheostomy.

Perform postmortem care.

Answer and Explanation

The Correct Answer is D

A.   Changing a dressing on an implanted central venous access device involves a sterile procedure and assessment, requiring the skills and knowledge of a licensed nurse.
B.   Removing an NG tube is a task beyond an AP’s scope and requires the specialized skills of a registered nurse.
C.   Suctioning a tracheostomy requires specialised training and skill to perform safely and should not be delegated to assistive personnel.
D.   Performing postmortem is within the scope of an assistive personnel. It does not require any specialized skills and knowledge of a registered nurse.

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Correct Answer is C

Explanation

A. Reevaluating for an ET cuff leak is important but not the immediate priority when the cause of the alarm is unknown, and the client is in distress. It is more important to ensure the client is receiving adequate ventilation.

B. Assessing for disconnected tubing is essential, but if the cause of the high-pressure alarm is unclear and the client is in distress, manual ventilation should take precedence.

C. When a high-pressure alarm sounds on a mechanical ventilator and the cause is not immediately identifiable, the nurse should prioritize the client's safety by delivering breaths manually with a resuscitation bag. This ensures that the client continues to receive oxygen while troubleshooting the ventilator issue. Manual ventilation is crucial in preventing hypoxia during periods of mechanical failure or when the cause of the alarm cannot be quickly identified.

D. Decreasing the ventilator flow rate may not address the underlying issue causing the high-pressure alarm and could potentially worsen the situation. Immediate manual ventilation is the safest action.

A. Apply the patch within 1 hr of removing it from the protective pouch. B. Shave hairy areas of skin prior to application. C. Wear gloves to apply the patch to the client's skin. D. Remove the previous patch and place it in a tissue.

Correct Answer is C

Explanation

A. Transdermal nicotine patches should be applied immediately after removal from the protective pouch, but waiting for up to 1 hour is acceptable according to most manufacturers' instructions.
B. Shaving hairy areas of skin is not necessary prior to applying a transdermal nicotine patch and may cause skin irritation.
C. Wearing gloves during the application of the transdermal nicotine patch helps to prevent nicotine absorption through the nurse's skin and reduces the risk of accidental exposure.
D. The nurse should properly dispose of the previous patch according to facility protocols rather than placing it in a tissue, as used nicotine patches can still contain active medication and pose a risk of exposure.

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A nurse is assigning tasks to an assistive personnel (AP). Which of the following tasks should the nurse assign to the AP?

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client receiving mechanical ventilation via an endotracheal (ET) tube. The high-pressure alarm is beeping, and the client is experiencing respiratory distress. The nurse is unable to determine the cause of the alarm. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

A nurse is preparing to apply a transdermal nicotine patch for a client. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

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