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?
Measure the intake and output of a client who has received furosemide.
Reinforce teaching with a client about crutch-gait walking.
Check a client's peripheral IV site for redness or swelling.
Assess the pain level of a client who has received acetaminophen.
The Correct Answer is A
Choice A Reason:
Measuring the intake and output of a client who has received furosemide is correct. This task involves recording and measuring fluid intake and output, which is typically within the scope of practice for assistive personnel. It requires accurate documentation and doesn't involve making clinical judgments.
Choice B Reason:
Reinforcing teaching with a client about crutch-gait walking is incorrect. Teaching and instructing clients about specific medical procedures or techniques usually require specialized knowledge and assessment skills, typically within the nurse's scope of practice.
Choice C Reason:
Checking a client's peripheral IV site for redness or swelling is incorrect. Assessing for redness or swelling at an IV site involves clinical judgment and assessment skills to identify potential complications. This task is better suited for a licensed nurse who can interpret findings and take appropriate action if needed.
Choice D Reason:
Assessing the pain level of a client who has received acetaminophen is incorrect. Assessing pain levels involves subjective interpretation and understanding of pain scales, which generally falls under the scope of licensed healthcare providers who can evaluate and manage pain interventions based on assessments.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A Reason:
Discontinuing supplements containing vitamin C 24 hr. before the test is incorrect. While high doses of vitamin C might interfere with the accuracy of some laboratory tests, it typically doesn't impact fecal occult blood testing. However, it's always best to follow specific instructions provided by the healthcare provider or laboratory.
Choice B Reason:
Refraining from consuming pork 7 days before the test. There isn't typically a requirement to avoid specific foods, such as pork, before a fecal occult blood test. The test is designed to detect blood in the stool, regardless of the diet. However, some dietary restrictions might be advised based on specific instructions or conditions, but these are not universally applicable.
Choice C Reason:
Placing a thick layer of stool on the specimen card is incorrect. When collecting a sample for a fecal occult blood test, it's important to follow the specific instructions provided by the healthcare provider or laboratory. Generally, a small portion of stool is applied to the designated area on the specimen card as instructed, rather than applying a thick layer. Applying too much stool can affect the accuracy of the test.
Choice D Reason:
Urinating prior to collecting the stool specimen is correct. This instruction ensures that the urine doesn't contaminate the stool sample, which could potentially affect the accuracy of the test results.
Correct Answer is D
Explanation
Choice A Reason:
Urinating after the specimen collection is incorrect. While it's important to ensure urine doesn't contaminate the stool specimen during collection, the instruction to urinate after the collection doesn't directly impact the collection process itself. The primary focus is on avoiding contamination of the stool sample with urine or toilet tissue during collection.
Choice B Reason:
Placing 1.3 cm (0.5 in) of formed stool into a culture tube is incorrect. The amount of stool needed for a specimen can vary based on the specific test requirements or laboratory instructions. A fixed measurement, like 1.3 cm of formed stool, might not accurately represent the necessary quantity for all types of stool tests. Specific instructions from the healthcare provider or laboratory should be followed for proper collection.
Choice C Reason:
Keeping the specimen in a warm area is incorrect. Stool specimens are typically collected and stored at room temperature unless otherwise specified by specific test instructions. Placing the specimen in a warm area could alter the characteristics of the sample or promote bacterial growth, potentially affecting test accuracy. The specimen should be handled according to the specific requirements outlined for the particular test.
Choice D Reason:
Avoid placing toilet tissue in the bedpan after defecation is correct. Placing toilet tissue in the bedpan after defecation can contaminate the stool specimen, affecting the accuracy of test results. It's important to collect the stool sample without any contamination from toilet tissue or urine.
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