A nurse is caring for four clients. Which of the following tasks can the nurse delegate to an assistive personnel?

Provide discharge instructions.

Perform chest compressions during cardiac resuscitation

Perform a dressing change for a new amputee

Assess effectiveness of antiemetic medication

Answer and Explanation

The Correct Answer is B

A. Provide discharge instructions: Delivering discharge teaching requires nursing judgment, individualized education, and assessment of the client’s understanding. This task cannot be delegated to assistive personnel because it involves critical thinking and evaluation to ensure safe and effective patient self-care.

B. Perform chest compressions during cardiac resuscitation: Performing chest compressions is a technical skill that does not require nursing judgment and can be safely delegated to assistive personnel. During a code, APs can provide life-saving support under the direction of the RN or code team, making this task appropriate for delegation.

C. Perform a dressing change for a new amputee: Changing a surgical dressing, particularly for a new amputation, requires assessment of the wound, monitoring for signs of infection, and clinical judgment regarding complications. This task should remain the responsibility of the RN and is not suitable for delegation to an AP.

D. Assess effectiveness of antiemetic medication: Evaluating medication effectiveness involves clinical assessment and interpretation of patient response. This requires professional nursing judgment and cannot be delegated, as the RN must decide if additional interventions or medications are necessary.

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Correct Answer is A

Explanation

A. Alanine aminotransferase (ALT): ALT is an enzyme found primarily in the liver, and elevated levels indicate hepatocellular injury. Acetaminophen overdose can cause severe liver toxicity, so a rise in ALT reflects liver damage and is a key laboratory marker to monitor in this situation.

B. Thyroxine (T4): Thyroxine is a thyroid hormone and is unrelated to liver injury or acetaminophen toxicity. Changes in T4 levels do not provide information about organ damage resulting from an overdose.

C. Serum amylase: Serum amylase is an enzyme associated with pancreatic function. While elevated amylase indicates pancreatitis, it is not typically affected by acetaminophen overdose and does not reflect hepatotoxicity.

D. Creatinine kinase (CK): CK is an enzyme released from muscle tissue during injury or breakdown. While important in assessing muscle damage or rhabdomyolysis, it does not indicate liver damage from acetaminophen toxicity.

A. Administer terbutaline subcutaneously as needed for contractions. B. Monitor the client's blood pressure every 2 hr. C. Place suction equipment at the client's bedside. D. Notify the provider of a urinary output of less than 50 mL/hr.

Correct Answer is C

Explanation

A. Administer terbutaline subcutaneously as needed for contractions: Terbutaline is a tocolytic used to suppress preterm labor, not to manage preeclampsia or magnesium sulfate therapy. Its use is unrelated to the care of a client receiving magnesium sulfate for seizure prophylaxis.

B. Monitor the client's blood pressure every 2 hr: In severe preeclampsia, blood pressure should be monitored more frequently than every 2 hours—typically every 15–30 minutes initially—because rapid changes can occur, and close monitoring is critical to prevent complications.

C. Place suction equipment at the client's bedside: Magnesium sulfate can cause respiratory depression as a serious adverse effect. Having suction equipment readily available ensures immediate intervention if the client experiences decreased respiratory effort or airway compromise, making this an essential safety measure.

D. Notify the provider of a urinary output of less than 50 mL/hr: While low urine output can indicate magnesium accumulation or renal impairment, the typical threshold for concern is less than 30 mL/hr. Although monitoring output is important, immediate bedside readiness for respiratory support is the priority intervention when administering magnesium sulfate.

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A nurse is caring for four clients. Which of the following tasks can the nurse delegate to an assistive personnel?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

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Correct Answer is C

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