A nurse is caring for a group of clients and identifying what tasks she can delegate to an assistive personnel (AP). Which of the following tasks should the nurse delegate to an AP?
Administer a glycerin suppository to a client.
Provide home care instructions to a client's family member.
Suction a client's newly inserted tracheostomy.
Perform rescue breathing for a client who becomes unresponsive.
The Correct Answer is D
Choice A rationale
Administering a suppository is considered a medication administration task, which requires a licensed nurse to perform. This task involves critical thinking and a solid understanding of anatomy, physiology, and pharmacology, as well as the potential for adverse reactions. Therefore, this cannot be delegated to an assistive personnel (AP), whose scope of practice does not include medication administration.
Choice B rationale
Providing home care instructions is part of client education, which is a key responsibility of a licensed nurse. This task requires a thorough understanding of the client's condition, treatment plan, and the ability to assess their learning needs. An AP is not trained to assess, plan, or implement teaching plans for clients, so this task is outside their scope of practice.
Choice C rationale
Suctioning a newly inserted tracheostomy is a skilled and invasive procedure that carries a high risk of complications, such as hypoxemia, trauma, or infection. This procedure requires a nurse's professional judgment and a clear understanding of sterile technique. The AP's role is to provide basic care, not to perform such complex and high-risk procedures.
Choice D rationale
Performing rescue breathing, or cardiopulmonary resuscitation (CPR), is an emergency procedure that falls within the scope of an AP's training. All healthcare workers, including APs, are required to have a basic life support certification. In a medical emergency, every staff member is expected to perform basic life-saving measures, such as rescue breathing, to prevent further client harm. *.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Digoxin slows the heart rate by inhibiting the sodium-potassium pump, which increases intracellular calcium and enhances myocardial contractility. Tachycardia is an increase in heart rate, which is the opposite of the expected effect of digoxin. Bradycardia is a more common sign of digoxin toxicity.
Choice B rationale
Insomnia is not a recognized or common side effect of digoxin toxicity. The central nervous system effects of digoxin toxicity typically include confusion, fatigue, and lethargy. Digoxin does not directly interfere with the sleep-wake cycle in a way that would cause insomnia.
Choice C rationale
Hearing loss is not a known symptom of digoxin toxicity. The drug's primary effects are on the cardiovascular and gastrointestinal systems, and to a lesser extent, the central nervous system. Auditory disturbances are not a typical finding associated with the toxic effects of digoxin.
Choice D rationale
Digoxin toxicity often affects the central nervous system and sensory organs. The drug can cause visual disturbances such as blurred vision, photophobia, and a characteristic yellow-green halo around objects (xanthopsia), which is an early sign of toxicity. This effect is a result of digoxin's impact on neural pathways
Correct Answer is B
Explanation
Choice A rationale
Increasing the rate of formula delivery would worsen hyperosmolar dehydration. A faster rate delivers more solute-rich formula to the gastrointestinal tract in a shorter time, pulling more free water from the body's vascular space into the gut lumen via osmosis. This fluid shift further depletes the body's free water, intensifying the dehydration and increasing serum osmolality.
Choice B rationale
Hyperosmolar dehydration occurs when the body's free water is drawn into the gastrointestinal tract due to a high solute concentration in the enteral formula. By adding free water to the formula, the nurse dilutes the solution, lowering its osmolarity. This action helps to balance the osmotic gradient, reducing the fluid shift and preventing further dehydration.
Choice C rationale
Switching to a lactose-free formula is indicated for clients with lactose intolerance, which causes symptoms like diarrhea and bloating, but it does not directly address hyperosmolar dehydration. Hyperosmolar dehydration is related to the overall solute load and concentration of the formula, not specifically the presence or absence of lactose.
Choice D rationale
Repositioning the NG tube is an action to ensure proper placement and prevent complications like aspiration, but it does not resolve hyperosmolar dehydration. This type of dehydration is a systemic problem related to fluid and electrolyte balance, not a local issue with the tube's position within the gastrointestinal tract. *.
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