A nurse is coordinating the care of a group of clients with an assistive personnel (AP). Which of the following tasks should the nurse not assign to the AP?

Measure the intake and output of a client who has received furosemide.

Check a client’s peripheral IV site for redness or swelling.

Assess the pain level of a client who has received acetaminophen.

Reinforcing teaching with a client about crutch-gait walking

None

Answer and Explanation

The Correct Answer is C

- When coordinating the care of a group of clients with assistive personnel (AP), it's important to delegate tasks appropriately based on the AP's scope of practice and training. Here are the tasks that can be assigned to the AP:

Measure the intake and output of a client who has received furosemide: This task involves recording fluid intake and output, which is typically within the scope of practice for an AP, as long as they have been trained in the proper procedure and documentation.

Check a client’s peripheral IV site for redness or swelling: This task involves basic assessment and can be assigned to an AP, as long as they are familiar with the signs of potential complications related to IV sites and have been trained in the facility's protocol for reporting any issues.

Reinforcing teaching with a client about crutch-gait walking: Education and reinforcement of information provided by healthcare professionals can often be delegated to APs, especially if they have received training on the specific topic. However, it's important to ensure that the AP is knowledgeable about crutch-gait walking and the information they are reinforcing.

The task related to assessing pain (e.g., assessing the pain level of a client who has received acetaminophen) should generally be performed by a licensed healthcare provider, such as a nurse. Assessment of pain requires a deeper understanding of the client's pain experience and may involve making clinical decisions related to pain management.

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Correct Answer is D

Explanation

The correct answer is choice D. “I’ll think about my grandfather’s farm to reduce pain.” This statement indicates an understanding of guided imagery, which is a relaxation technique that aims to help lower the levels of stress hormones and pain perception by imagining a scene that involves each of the senses and positive emotions.

Guided imagery can help to distract from pain signals and reduce anxiety, which can also contribute to pain.

Choice A is wrong because it does not involve creating a specific imagined reality, but rather noticing the sensation of muscle tension, which may increase awareness of pain.

Choice B is wrong because it does not involve using all of the senses and emotions, but rather listening to music, which may be relaxing but not as effective as guided imagery for pain relief.

Choice C is wrong because it does not involve imagining a scene, but rather using focused breathing to control pain, which is another relaxation technique but not guided imagery.

A. “You will have to sign a release form to perform the care yourself.” B. “A licensed health care worker must perform postmortem care.”. C. “I will assist you in any way I can during this process.”. D. “This care takes place after the client leaves the facility.”.

Correct Answer is C

Explanation

The correct answer is choice C. “I will assist you in any way I can during this process.” This response shows sensitivity and respect for the client’s family and their cultural or religious beliefs. Postmortem care involves caring for a deceased patient’s body with dignity and in a manner that is consistent with the patient’s and family’s wishes.The nurse should offer to assist the family in performing the postmortem care if they request to do so.

Choice A is wrong because the family does not need to sign a release form to perform the postmortem care themselves.

There is no legal requirement for this.

Choice B is wrong because a licensed health care worker does not have to perform postmortem care.

The family can perform the care themselves if they wish, with or without the assistance of a health care worker.

Choice D is wrong because postmortem care takes place before the client leaves the facility, not after.

Postmortem care should be provided as soon as possible to prevent tissue damage or disfigurement.

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A nurse is coordinating the care of a group of clients with an assistive personnel (AP). Which of the following tasks should the nurse not assign to the AP?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reinforcing teaching with a client about using guided imagery to manage chronic pain. Which of the following statements by the client indicates an understanding of this technique?

Correct Answer is D

Explanation

A nurse in an acute care center is caring for a client who just died. The client’s family requests to perform the postmortem care. Which of the following is an appropriate response for the nurse to make?

Correct Answer is C

Explanation

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