A nurse is assisting with planning care for a group of clients. Which of the following tasks should the nurse delegate to an assistive personnel?
Changing the dressing on a client's IV site
Suctioning a client's new tracheostomy
Evaluating a client's risk for developing pressure injuries
Administering a large-volume enema to a client
None
None
The Correct Answer is A
A. Changing the dressing on a client's IV site: This is a sterile procedure and requires the nurse’s clinical expertise. It cannot be delegated to assistive personnel (AP).
B. Suctioning a client's new tracheostomy: Suctioning a tracheostomy, especially a new one, is a sterile procedure requiring clinical judgment and skill, which is beyond the scope of assistive personnel.
C. Evaluating a client's risk for developing pressure injuries: This is an assessment task that requires clinical judgment and critical thinking. It falls under the nurse’s scope of practice and should not be delegated to AP.
D. Administering a large-volume enema to a client: Assisting with or administering an enema is a task that can be delegated to assistive personnel, as it is within their scope of practice, provided the client is stable and the procedure does not require complex judgment.
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Related Questions
Correct Answer is C
Explanation
A. The television set turned to a loud volume may not necessarily pose a safety hazard unless it disturbs others in the household or contributes to hearing damage. However, it is not a direct safety concern for the client.
B. The dining room table having low chairs with no armrests could present a challenge for older adults when sitting down or getting up, but it is not an immediate safety hazard.
C. The bedroom extension cord placed under a heavy nightstand is a safety hazard because it poses a risk of electrical fire if the cord becomes damaged or overloaded. The nurse should
intervene to relocate the extension cord to a safer location.
D. The presence of wall-to-wall carpeting in the living room is not necessarily a safety hazard unless it is loose or torn, posing a tripping hazard. However, it is not explicitly described as such in the scenario.
Correct Answer is D
Explanation
A. Hypernatremia: Hypernatremia (elevated sodium levels) is not typically associated with the emergent phase of burn injuries.
B. Hypercalcemia: Hypercalcemia (elevated calcium levels) is not typically associated with the emergent phase of burn injuries.
C. Hypermagnesemia: Hypermagnesemia (elevated magnesium levels) is not typically associated with the emergent phase of burn injuries.
D. Hyperkalemia: Hyperkalemia (elevated potassium levels) is a common electrolyte imbalance seen in the emergent phase of burn injuries due to the release of potassium from damaged cells.
It can lead to cardiac dysrhythmias and other complications if not promptly addressed.
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