A nurse is coordinating care of a group of clients with an assistive personnel (AP). Which of the following tasks should the nurse assign to the AP?
A. Assess the pain level of a client who has received acetaminophen.
Check a client's peripheral IV site for redness or swelling.
Measure the intake and output of a client who has received furosemide.
Reinforce teaching with a client about crutch-gait walking.
The Correct Answer is C
Choice A rationale
Assessing pain levels is a nursing task requiring clinical judgment, which is beyond the scope of an assistive personnel's duties.
Choice B rationale
Checking an IV site for redness or swelling also requires clinical assessment skills, which are tasks for the nurse.
Choice C rationale
Measuring intake and output is a routine task that can be safely delegated to an assistive personnel. It involves straightforward measurement and recording.
Choice D rationale
Reinforcing teaching about crutch-gait walking requires specific patient education, which falls under the nurse's responsibilities.
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Related Questions
Correct Answer is D
Explanation
Choice A rationale
Drinking citrus juice with meals can irritate the bladder and exacerbate urinary incontinence due to the high acidity in citrus fruits. It is not recommended for individuals with urinary incontinence.
Choice B rationale
Training the bladder by voiding every 5 hours is too infrequent for most individuals. Bladder training usually involves more frequent voiding intervals to gradually increase the bladder's capacity to hold urine.
Choice C rationale
Applying adult diapers at bedtime can be useful in managing nighttime incontinence but does not address the underlying issue or provide a long-term solution for urinary incontinence.
Choice D rationale
Performing pelvic-muscle exercises, also known as Kegel exercises, can strengthen the pelvic floor muscles and improve bladder control, making it an effective method for managing urinary incontinence.
Correct Answer is A
Explanation
Choice A rationale
Flexing hips and knees when assisting the client to a standing position uses proper body mechanics, reducing the risk of injury to both the nurse and the client. It provides a stable base of support during the transfer.
Choice B rationale
Pivoting on the foot farthest from the bed when assisting the client into the chair is incorrect. The nurse should pivot on the foot closest to the bed to maintain balance and control during the transfer.
Choice C rationale
Standing on the client's stronger side when moving the client into the chair is incorrect. The nurse should stand on the client's weaker side to provide support and prevent falls.
Choice D rationale
Raising the bed to waist level before moving the client is incorrect as it may not provide the best ergonomic position for the transfer. The bed should be at a height that ensures the nurse’s safety and facilitates the client's movement.
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