A nurse is delegating care for a client who has right-sided weakness following a cerebrovascular accident. The client coughs when eating and voice becomes hoarse after swallowing. Select the four tasks the nurse should assign to an assistive personnel.
Ambulate the client.
Document the client's urine output.
Assist the client with completing their food menu.
Instruct the client on swallowing techniques.
Obtain the client's vital signs.
Refer the client to the speech language pathologist
Correct Answer : A,B,C,E
Choice A: Ambulate the client
Ambulating the client is a task that can be safely delegated to assistive personnel. The client has right-sided weakness following a cerebrovascular accident, and assistive personnel can help the client move around safely¹.
Choice B: Document the client's urine output
Documenting the client's urine output is another task that can be delegated to assistive personnel. They are trained to measure and record urine output, which is important for monitoring the client's fluid balance¹.
Choice C: Assist the client with completing their food menu
Assistive personnel can also help the client with completing their food menu. This task does not require clinical judgement and can be safely delegated¹.
Choice D: Instruct the client on swallowing techniques
Instructing the client on swallowing techniques should not be delegated to assistive personnel. This task requires specialized knowledge and skills that are beyond the scope of practice for assistive personnel².
Choice E: Obtain the client's vital signs
Obtaining the client's vital signs is a task that can be delegated to assistive personnel. They are trained to accurately measure and record vital signs, which are crucial for monitoring the client's health status¹.
Choice F: Refer the client to the speech language pathologist
Referring the client to the speech language pathologist is not a task that can be delegated to assistive personnel. This decision requires clinical judgement and should be made by the nurse².
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Evaluating the outcomes is not the first step in the evidence-based practice process, but the last one. The nurse should evaluate the outcomes after implementing the findings and comparing them with the expected results.
Choice B reason: Implementing the findings is not the first step in the evidence-based practice process, but the fourth one. The nurse should implement the findings after searching for evidence, appraising the quality and relevance of the evidence, and synthesizing the evidence.
Choice C reason: Formulating a question is the first step in the evidence-based practice process, as it helps to define the problem, the population, the intervention, the comparison, and the outcome. The nurse should formulate a question that is clear, specific, and answerable.
Choice D reason: Searching for evidence is not the first step in the evidence-based practice process, but the second one. The nurse should search for evidence after formulating a question, using appropriate sources, keywords, and strategies.
Correct Answer is B
Explanation
Choice A reason: The belief that the client has a difficult relationship with his son is not relevant for the change-of-shift report. This is a subjective and personal opinion that does not affect the client's care or recovery.
Choice B reason: The steps to follow when providing wound care is relevant for the change-of-shift report. This is an objective and clinical information that ensures the continuity and quality of the client's care.
Choice C reason: The time the client received his last dose of pain medication is not relevant for the change-of-shift report. This is a routine and standard information that can be found in the medication administration record or the electronic health record.
Choice D reason: The client's preferred time for bathing is not relevant for the change-of-shift report. This is a preference and not a priority information that can be communicated later or documented in the care plan.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.