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 A
Explanation
Choice A rationale
Determining the accepted standards for hand hygiene is the first and most critical step in an audit. Without a clear set of criteria, there is no basis for evaluating current practices. This standard serves as a benchmark against which all subsequent data will be measured, ensuring the audit is objective and that any deviations can be accurately identified.
Choice B rationale
Establishing data collection methods is a crucial step, but it must follow the establishment of standards. The methods for data collection, such as direct observation or surveys, must be designed to accurately measure adherence to the predetermined standards. Without standards, the data collected would lack context and a meaningful reference point for analysis.
Choice C rationale
Comparing facility data to established criteria is a subsequent step in the audit process. It involves analyzing the collected data to determine whether current practices align with the accepted standards. This comparison identifies gaps in compliance, but it can only be done after the standards have been defined and data has been collected.
Choice D rationale
Corrective measures are a final step in the quality improvement cycle. They are implemented after data has been collected, analyzed, and a need for change has been identified. Taking corrective action before an audit is completed would be premature and lacks an evidence-based foundation, potentially leading to ineffective or misdirected interventions. *.
Correct Answer is D
Explanation
Choice A rationale
Amnioinfusion is the infusion of saline into the amniotic cavity. It is used to treat umbilical cord compression or meconium staining, not to manage seizures. Initiating an amnioinfusion during a seizure would be an inappropriate and ineffective intervention that would not address the underlying physiological cause of eclampsia or the immediate post-seizure recovery.
Choice B rationale
An internal fetal heart monitor is an invasive procedure requiring the rupture of membranes and insertion of a fetal spiral electrode. This is not the priority action following a seizure. Post-seizure priority is maternal stabilization, ensuring a patent airway, and preventing further injury. External fetal monitoring is the standard first-line approach to assess fetal well-being.
Choice C rationale
Calcium gluconate is the antidote for magnesium sulfate toxicity, not a treatment for seizures. Administering calcium gluconate would be inappropriate unless magnesium toxicity (e.g., respiratory depression) is suspected. The primary treatment for eclamptic seizures is magnesium sulfate, which works by depressing the central nervous system and blocking neuromuscular conduction.
Choice D rationale
Placing the client on her side is the priority action following a seizure. This position prevents aspiration of secretions, promotes venous return to the heart, and improves placental perfusion. This is a critical safety measure to protect both the mother and the fetus from further harm and is part of standard post-ictal care. *.
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