A nurse is delegating client care tasks to assistive personnel. Which of the following tasks should the nurse delegate?

Evaluating the healing of an incision

Changing IV tubing

Performing a simple dressing change

Inserting an NG tube

Answer and Explanation

The Correct Answer is B

Choice A reason:
Evaluating the healing of an incision is not necessary because it involves clinical judgment and assessment skills, which are generally beyond the scope of practice for assistive personnel.
Choice B reason:
Changing IV tubing is a task that can often be safely delegated to an assistive personnel (AP) who has been trained and deemed competent to perform this task. It is within the AP's scope of practice and doesn't require clinical judgment or assessment.
Choice C reason:
Performing a simple dressing change involves direct contact with a wound and requires knowledge of aseptic technique and wound care principles. This task is typically performed by licensed nursing personnel.
Choice D reason:
Inserting an NG tube is a complex procedure that requires specialized training and skill. It should be performed by a licensed nurse or another healthcare professional with the appropriate training and competence.

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Correct Answer is C

Explanation

Choice A reason:
Palpation can help assess for tenderness, rigidity, or masses in the abdomen, which might indicate infection, bleeding, or other complications. However, palpation could potentially worsen a condition such as an evisceration or dehiscence, or cause additional pain. Therefore, palpation should be done only after the visual inspection and with great caution in the presence of severe pain.
Choice B reason:
Percussion is useful for assessing the presence of gas, fluid, or solid masses in the abdomen. Resonance might indicate normal air-filled intestines, while dullness could suggest fluid or mass. However, percussion is not the first action in an acute setting of sudden severe pain because it does not provide immediate information that could be life-saving. It is a later step in the physical examination.
Choice C reason:
Visual inspection is the first step because it can quickly reveal critical signs such as swelling, distention, redness, or evidence of wound complications like dehiscence or evisceration. Identifying these signs early allows for rapid intervention, which could be life-saving. This is why exposing and inspecting the abdomen is the priority in the context of sudden severe pain following surgery.
Choice D reason:
Listening for bowel sounds can provide information about the function of the gastrointestinal system. Absence of bowel sounds might suggest a paralytic ileus, while hyperactive sounds could indicate a bowel obstruction. However, in the context of sudden, severe abdominal pain postoperatively, auscultation is not the first priority.

A. "OJ" for orange juice B. "SS" for sliding scale C. "SQ" for subcutaneous D. "BRP" for bathroom privileges

Correct Answer is D

Explanation

a."OJ" for orange juice is not recommended. While it might seem straightforward, "OJ" could be confused with "oj" or other abbreviations, leading to potential confusion. It's better to write out "orange juice."

b."SS" for sliding scale is not recommended" could be misinterpreted or confused with other meanings. It's safer to write out "sliding scale."

c.SQ is commonly mistaken as “5 every”.Use SUBQ (all UPPERCASE letters, without spaces or periods between letters), or subcutaneous(ly).

d.This is a commonly accepted abbreviation in medical documentation, meaning bathroom privileges.

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A nurse is delegating client care tasks to assistive personnel. Which of the following tasks should the nurse delegate?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is D

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