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 ["50"]
Explanation
Let's calculate the rate for the IV infusion.
We are given:
Volume to be infused: 400 mL
Infusion time: 8 hours
Drop factor: 60 gtt/mL
We need to find the rate in gtt/min.
Here's how we can do it:
Convert hours to minutes: Since the rate is required in minutes, we need to convert the infusion time from hours to minutes. There are 60 minutes in 1 hour. Therefore, total infusion time in minutes = 8 hours x 60 minutes/hour = 480 minutes
Calculate total number of drips: We can find the total number of drips to be delivered by multiplying the volume (in mL) by the drop factor (gtt/mL). Total drips = Volume (mL) x Drop factor (gtt/mL) = 400 mL x 60 gtt/mL = 24000 gtt
Calculate drip rate (gtt/min): Finally, we can calculate the rate by dividing the total number of drips by the total infusion time in minutes. Rate (gtt/min) = Total drips (gtt) / Total time (minutes) = 24000 gtt / 480 minutes = 50 gtt/min
Therefore, the nurse should set the manual IV infusion to deliver approximately 50 gtt/min.
Correct Answer is A
Explanation
(A) Heart murmur: This is the most appropriate answer. Mitral valve stenosis can cause a heart murmur due to turbulent blood flow across the narrowed mitral valve. This is often heard best at the apex of the heart with the patient in the left lateral decubitus position.
(B) Clubbing of the fingers: Clubbing of the fingers is typically associated with conditions that cause chronic hypoxia, such as lung disease or congenital heart disease. It is not a common finding in mitral valve stenosis.
(C) Bradycardia: Mitral valve stenosis does not typically cause bradycardia. In fact, some patients may have a rapid heart rate (tachycardia) due to atrial fibrillation, which is a common complication of mitral valve stenosis.
(D) Barrel chest: A barrel chest is typically associated with chronic obstructive pulmonary disease (COPD) and is not a common finding in mitral valve stenosis. It refers to a rounded, bulging chest that resembles the shape of a barrel. This occurs due to overinflation of the lungs over a long period of time.
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