A nurse is caring for four clients. Which of the following tasks should the nurse delegate to an assistive personnel (AP)?
Evaluate dietary intake for a client who has anorexia.
Measure the vital signs of a client who just returned from the PACU
Arrange the lunch tray for a client who has a hip fracture.
Assess I&O for a client who is receiving dialysis.
The Correct Answer is C
A. Incorrect. Evaluating dietary intake requires nursing judgment and knowledge of nutrition and eating disorders. This task should not be delegated to an AP.
B. Incorrect. Measuring vital signs of a postoperative client requires nursing assessment and monitoring for complications. This task should not be delegated to an AP.
C. Correct. Arranging the lunch tray for a client who has a hip fracture is a routine task that does not require nursing skills or judgment. This task can be delegated to an AP.
D. Incorrect. Assessing I&O for a client who is receiving dialysis requires nursing knowledge of fluid and electrolyte balance and renal function. This task should not be delegated to an AP.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C","D","E"]
Explanation
Extremity pulse +3, Capillary refill 2 seconds, Right extremity is warm to the touch, Adolescent reports no numbness or tingling, Adolescent reports pain as 2 on a scale of 0 to 10.
Correct Answer is B
Explanation
- Urinary output is an important indicator of fluid balance and kidney function. After delivery, a woman may experience increased urinary output due to the loss of excess fluid that was retained during pregnancy and the diuretic effect of oxytocin, which is released during breastfeeding. This is a normal and expected finding in the postpartum period.
- However, increased urinary output may also be a sign of urinary retention, which is the inability to empty the bladder completely. Urinary retention can occur due to trauma to the bladder or urethra during delivery, swelling or hematoma of the perineum, epidural anesthesia, or decreased bladder sensation.Urinary retention can lead to complications such as infection, bladder distension, or postpartum hemorrhage.
- Therefore, when a woman who delivered a normal newborn 24 hours ago reports that she seems to be urinating every hour or so, the practical nurse (PN) should measure the next voiding, then palpate the client's bladder. This will help to assess the amount and quality of urine and the presence or absence of bladder distension. A normal urine output is about 30 ml per hour, and a normal bladder should feel soft and empty after voiding. If the urine output is low or high, or if the bladder feels firm or full after voiding, the PN should report these findings to the primary healthcare provider for further evaluation and intervention.
Therefore, option B is the correct answer, while options A, C, and D are incorrect.
Option A is incorrect because catheterizing the client for residual urine volume is an invasive procedure that should only be done if indicated by the primary healthcare provider.
Option C is incorrect because evaluating for normal involution and massaging the fundus are related to uterine function, not urinary function.
Option D is incorrect because obtaining a specimen for urine culture and sensitivity is not necessary unless there are signs of infection, such as fever, dysuria, or foul-smelling urine.
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