A nurse is delegating client care to an assistive personnel (AP). Which of the following tasks should the nurse assign to the AP?
A. Administering vaginal cream to a client who has a vaginal infection.
Providing postmortem care for a client who has just died.
Suctioning a tracheostomy for a client who has a recent head injury.
Changing a peripheral IV dressing for a client who is postoperative.
The Correct Answer is B
Choice A rationale
Administering vaginal cream is a medication administration task requiring knowledge and skills within the licensed nurse's scope of practice. Assistive personnel (AP) are not authorized to perform this procedure due to the potential for complications and the need for clinical judgment.
Choice B rationale
Providing postmortem care is a task that AP can perform as it involves basic care activities, such as bathing and positioning, which do not require specialized nursing skills. This allows the nurse to focus on more complex patient needs.
Choice C rationale
Suctioning a tracheostomy is a procedure that requires clinical assessment and intervention skills. Due to the potential for complications, it is within the licensed nurse's scope of practice, not the AP's.
Choice D rationale
Changing a peripheral IV dressing involves assessment skills and requires sterile technique to prevent infection. This task is beyond the scope of practice for AP and should be performed by a licensed nurse.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Administering vaginal cream is a medication administration task requiring knowledge and skills within the licensed nurse's scope of practice. Assistive personnel (AP) are not authorized to perform this procedure due to the potential for complications and the need for clinical judgment.
Choice B rationale
Providing postmortem care is a task that AP can perform as it involves basic care activities, such as bathing and positioning, which do not require specialized nursing skills. This allows the nurse to focus on more complex patient needs.
Choice C rationale
Suctioning a tracheostomy is a procedure that requires clinical assessment and intervention skills. Due to the potential for complications, it is within the licensed nurse's scope of practice, not the AP's.
Choice D rationale
Changing a peripheral IV dressing involves assessment skills and requires sterile technique to prevent infection. This task is beyond the scope of practice for AP and should be performed by a licensed nurse.
Correct Answer is C
Explanation
Choice A rationale
Hyperactive bowel sounds indicate increased gastrointestinal activity, often associated with conditions like gastroenteritis or diarrhea. While it requires monitoring, it is not immediately concerning in the context of administering medications via a gastrostomy tube.
Choice B rationale
Yellowish-green stomach contents suggest the presence of bile, a normal finding in gastric aspirates. It indicates that the tube is correctly placed in the stomach, which is crucial before administering medications.
Choice C rationale
A pH of 6.5 for aspirated stomach contents suggests that the tube might be dislocated into the respiratory tract or intestines, as normal gastric pH ranges from 1.5 to 3.5. Reporting this finding is critical to avoid complications.
Choice D rationale
A residual volume of 90 mL is within the acceptable range for most clients with gastrostomy tubes. High residual volumes (usually over 200 mL) are more concerning and may require intervention.
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