A nurse is delegating tasks for an assistive personnel (AP) to perform for a client who is 1-day postoperative following cardiac surgery. Which of the following tasks should the nurse perform herself?
Helping the client into the shower
Ambulating the client in the hallway
Measuring vital signs
Removing the sternal dressing
The Correct Answer is D
A. Helping the client into the shower: This task can be safely delegated to an assistive personnel (AP). The AP can help the client with activities of daily living such as showering, as long as the client is stable and does not require close monitoring.
B. Ambulating the client in the hallway: This task can also be delegated to an AP. Assisting with ambulation is within the scope of practice for an AP, provided the client is stable and there are no specific concerns that require a nurse’s assessment.
C. Measuring vital signs: While measuring vital signs is a critical task, it can be delegated to an AP. The AP can be trained to accurately measure and report vital signs. However, the nurse should review and interpret the results.
D. Removing the sternal dressing: This is the correct answer. Removing a sternal dressing after cardiac surgery is a complex task that requires a nurse’s expertise2. The nurse needs to assess the surgical site for signs of infection or complications, which is beyond the scope of practice for an AP. Therefore, this task should not be delegated and should be performed by the nurse herself
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["2"]
Explanation
To find out how many aspirin tablets the nurse should administer, we can divide the prescribed dosage by the amount of aspirin per tablet:
Dosage m prescribed: 650 mg
Amount of aspirin per tablet: 325 mg/tablet
Number of tablets = Dosage prescribed / Amount of aspirin per tablet
Number of tablets = 650 mg / 325 mg/tablet = 2 (rounded to the nearest whole number)
Therefore, the nurse should administer 2 tablets.
Correct Answer is B
Explanation
(A) Re-collection of data: Re-collection of data is not the next step after planning. It might be done as part of the evaluation step or if there are significant changes in the client’s condition.
(B) Implementation: This is the most appropriate answer. After the planning step of the nursing process, the nurse moves on to the implementation step. This is where the nurse executes the interventions that were identified during the planning step.
(C) Data Collection: Data collection is typically the first step in the nursing process, where the nurse gathers information about the client’s health status. It is not the next step after planning.
(D) Evaluation: Evaluation is the final step of the nursing process. It involves assessing the client’s response to the nursing interventions and determining whether the client’s goals have been met. It is not the next step after planning.
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