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. *.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
An acute hemolytic transfusion reaction is a severe and life-threatening reaction caused by an incompatibility between the donor's blood and the client's blood. The recipient's antibodies attack and destroy the transfused red blood cells, leading to hemolysis. The classic symptoms include chills, fever, low-back pain, tightness in the chest, and headache. This reaction is a medical emergency requiring immediate cessation of the transfusion and supportive care.
Choice B rationale
An allergic reaction to a blood transfusion is typically caused by the recipient's antibodies reacting to a foreign plasma protein in the donor blood. Symptoms can range from mild, such as hives and itching, to severe, such as anaphylaxis. However, symptoms like low-back pain and a feeling of "tightness" in the chest are more characteristic of a hemolytic reaction rather than a simple allergic response.
Choice C rationale
A febrile nonhemolytic transfusion reaction is the most common type of transfusion reaction. It is caused by the recipient's antibodies reacting to donor white blood cells. Symptoms include fever and chills, but typically do not include the severe manifestations of low-back pain, headache, and chest tightness that are seen in a hemolytic reaction. The reaction is usually not life-threatening.
Choice D rationale
Transfusion-related acute lung injury (TRALI) is a serious and potentially fatal complication of a transfusion. It is characterized by the sudden onset of non-cardiogenic pulmonary edema within six hours of a transfusion. Symptoms primarily involve respiratory distress, such as dyspnea and hypoxemia. While TRALI is severe, the symptoms presented, particularly the low-back pain and chest tightness, are more indicative of an acute hemolytic reaction. .
Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"A"}
Explanation
Why Safety Comes First
- The client presents with multiple red flags for physical abuse and neglect, including bruises in various stages of healing, a fracture, and concerning behavior around the adult child.
- Ensuring the client is in a safe environment is the top priority to prevent further harm and initiate protective interventions.
Why Nutritional Status Is Next
- The client reports limited food availability and has a low BMI (18.3), suggesting possible malnutrition.
- Addressing nutritional needs is essential for recovery and overall well-being, especially in older adults who are vulnerable to rapid health decline.
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