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

Answer and Explanation

The Correct Answer is D

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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Correct Answer is C

Explanation

A. Lip-smacking may indicate hunger or a desire to feed but is not necessarily indicative of pain in a newborn with shoulder dystocia.
B. Stiff posture may indicate discomfort or distress, but it is not specific to pain and can be caused by various factors.
C. A weak cry can be a sign of pain or distress in newborns. It may indicate that the newborn is experiencing discomfort related to the shoulder dystocia.
D. Tongue-darting is a normal reflex in newborns and is not typically associated with pain.

A. Flush the tubing. B. Clamp the tubing. C. Check patency of the tubing. D. Aspirate the tubing.

Correct Answer is A

Explanation

A. This is the correct answer. Flushing the tubing with water after medication administration ensures that the medication reaches the stomach and prevents any residue from remaining in the tubing.
B. Clamping the tubing is not typically necessary after medication administration and may impede the flow of subsequent medications or enteral feedings.
C. While checking the patency of the tubing is important before medication administration, it is not specifically performed after administering the medication.
D. Aspirating the tubing after medication administration is not necessary and may disrupt the delivery of the medication into the stomach.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is collecting data from a newborn who has shoulder dystocia. The nurse should identify which of the following findings as an indication of pain?

Correct Answer is C

Explanation

A nurse is preparing to administer medication to a child through an enteral tube. Which of the following actions should the nurse take after administering the medication?

Correct Answer is A

Explanation

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