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:
"Encourage your partner to eat three large meals each day." Is incorrect. At the end of life, a patient's appetite might decrease, and they may not tolerate large meals. Encouraging large meals can cause discomfort or be inappropriate for their condition.
Choice B Reason:
"We will use an electric blanket to keep your partner warm." Is incorrect. While maintaining comfort is important, the use of an electric blanket might not be suitable as the patient's circulation and ability to regulate body temperature might be compromised.
Choice C Reason:
"Opioids will be restricted if your partner develops respiratory distress." Is incorrect.
Opioids can be appropriate for managing symptoms like pain or dyspnea at the end of life. Restricting opioids solely due to the risk of respiratory distress might hinder adequate symptom management. The use of opioids should be based on individual patient needs and careful assessment by healthcare providers.
Choice D Reason:
"Assume your partner can hear you, even if they do not respond." Is correct. This statement encourages communication and acknowledges the possibility that the patient might still be able to perceive their surroundings, even if they are not responsive. It supports the importance of providing emotional support and communication during the end-of-life process.
Correct Answer is B
Explanation
Choice A Reason:
Applying intermittent suction for up to 30 seconds is incorrect. While suctioning is necessary for tracheostomy care, the duration and frequency of suctioning should be based on the client's need and should typically last no more than 10-15 seconds to prevent hypoxemia and tissue damage.
Choice B Reason:
Preoxygenate the client prior to suctioning is correct. Preoxygenation helps ensure that the client has adequate oxygen levels before the suctioning procedure, reducing the risk of hypoxemia or decreased oxygen levels during and after suctioning
Choice C Reason:
Instruct the client to swallow during catheter insertion is incorrect. Instructing the client to swallow during catheter insertion is not a standard procedure for tracheostomy care. Swallowing doesn't have a direct association with the suctioning process.
Choice D Reason:
Apply suction while inserting the catheter is incorrect. Applying suction during catheter insertion can cause tissue damage and should be avoided. Suction should only be applied when withdrawing the catheter to remove secretions from the tracheostomy tube.
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