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.

Answer and Explanation

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.

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Correct Answer is C

Explanation

Choice A Reason:

"I'll use focused breathing to control my pain." Is incorrect. Focused breathing is a relaxation technique that can complement guided imagery, but it's not specifically imagery-based. It's more aligned with techniques like mindfulness or deep breathing exercises.

Choice B Reason:

"I'll learn to notice the sensation of muscle tension." Is incorrect. Noticing muscle tension is a part of progressive muscle relaxation, a different technique aimed at reducing physical tension, which is different from guided imagery.

Choice C Reason:

"I'll think about my grandfather's farm to reduce pain." Is correct. Guided imagery involves focusing on specific mental images or scenarios to promote relaxation, reduce stress, and manage pain. Imagining a peaceful or pleasant place, like the client's grandfather's farm, can serve as a distraction and help reduce pain perception.

Choice D Reason:

"I'll listen to my favorite music to take my mind off the pain." Is incorrect. Listening to music can be a distraction technique, but it's not specifically guided imagery. While it might help in managing pain by diverting attention, it's not rooted in imagery-focused mental visualization.

A. "I can't change my mind about the care I will receive once I sign my living will." B. "If I want life support, I'll need to sign a separate consent form first." C. "I'm glad to have the opportunity to choose what kind care I receive while I still can." D. "Once I fill out my living will, there will be a 1-month delay before it is legally binding"

Correct Answer is C

Explanation

Choice A Reason:

"I can't change my mind about the care I will receive once I sign my living will." Is incorrect.

This statement suggests a misconception that signing a living will locks in a permanent decision, whereas advance directives can usually be updated or modified as long as the individual is competent to do so.

Choice B Reason:

"If I want life support, I'll need to sign a separate consent form first." Is incorrect. While the concept of a consent form for specific treatments is relevant, it might not fully reflect the broader scope of advance directives, which encompass a range of healthcare preferences beyond just life support.

Choice C Reason:

"I'm glad to have the opportunity to choose what kind of care I receive while I still can." Is correct. This statement reflects the understanding that advance directives offer the opportunity to make decisions about the type of care the client wishes to receive or avoid, empowering them to express their preferences while they are still able to do so.

Choice D Reason:

"Once I fill out my living will, there will be a 1-month delay before it is legally binding." Is incorrect. There isn't typically a standardized waiting period before an advance directive becomes legally binding. The legal validity and activation of advance directives vary by region, but they usually become effective immediately upon completion unless stated otherwise or specific requirements apply.

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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?

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