A nurse is making client assignments for the next shift. The nurse should assign which of the following clients to the assistive personnel?

A client who requires sterile dressing changes every three hours

A client who has a small bowel obstruction and requires insertion of a nasogastric tube

A client who is postoperative and requires intake and output measurement every 2 hr

A client on hospice who is unstable and requires frequent vital sign checks

Answer and Explanation

The Correct Answer is C

A. A client who requires sterile dressing changes every three hours: Sterile dressing changes require skilled nursing care and must be performed by a licensed nurse. An assistive personnel (AP) is not trained or authorized to perform sterile procedures, making this assignment inappropriate.

B. A client who has a small bowel obstruction and requires insertion of a nasogastric tube: Inserting a nasogastric tube is an invasive procedure that requires clinical judgment and proper technique, which are responsibilities of licensed nursing staff, not assistive personnel.

C. A client who is postoperative and requires intake and output measurement every 2 hr: Measuring and recording intake and output is within the scope of practice for assistive personnel. It is a routine, noninvasive task that does not require nursing assessment or judgment.

D. A client on hospice who is unstable and requires frequent vital sign checks: An unstable hospice client requires close monitoring and clinical assessment. Although assistive personnel can measure vital signs, evaluating changes and determining their significance must be done by licensed nursing staff.

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Correct Answer is D

Explanation

A. "You will receive moderate sedation prior to the procedure.": Moderate sedation is not typically required for a thoracentesis. Instead, local anesthesia is used at the puncture site to minimize discomfort. The client remains awake, able to follow instructions, and does not require the same level of monitoring associated with moderate sedation.

B. "You will need to lie on your affected side for 30 minutes following the procedure.": After a thoracentesis, clients are usually positioned on the unaffected side to allow the lung on the affected side to re-expand and to minimize the risk of complications such as pneumothorax. Lying on the affected side could worsen the client's condition post-procedure.

C. "You will not be able to eat or drink four hours prior to the procedure.": Thoracentesis is not a gastrointestinal or airway procedure that necessitates fasting beforehand. Clients are typically allowed to eat and drink normally unless another procedure requiring fasting is planned, as the risk of aspiration is minimal with thoracentesis.

D. "You will be placed leaning over a bedside table during the procedure.": Clients undergoing thoracentesis are positioned sitting upright, leaning slightly forward over a bedside table with pillows for support. This position helps spread the ribs apart and provides the best access to the pleural space while minimizing the risk of lung injury.

A. Hold the catheter with the dominant hand during insertion. B. Advance catheter 7.5 cm (3 in) after urine begins to flow C. Hang collection bag below the level of the bladder. D. Lubricate the catheter 12.5 cm is in prior to insertion

Correct Answer is A

Explanation

A. Hold the catheter with the dominant hand during insertion: The dominant hand should be used to insert the catheter because it provides better control and precision during the sterile procedure. The nondominant hand is used to expose and maintain the position of the urethra but is considered contaminated once touching the client.

B. Advance catheter 7.5 cm (3 in) after urine begins to flow: The catheter should be advanced approximately 2.5 to 5 cm (1 to 2 inches) further after urine appears, not 7.5 cm. Advancing too far could cause discomfort or trauma to the bladder.

C. Hang collection bag below the level of the bladder: While this is an important step in managing the catheter after insertion to prevent backflow and infection, it does not specifically pertain to the insertion process itself.

D. Lubricate the catheter 12.5 cm (5 in) prior to insertion: Typically, for female catheterization, about 2.5 to 5 cm (1 to 2 inches) of the catheter is lubricated, not 12.5 cm. Excessive lubrication is unnecessary and may cause difficulty during insertion.

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A nurse is making client assignments for the next shift. The nurse should assign which of the following clients to the assistive personnel?

Nursing Test Bank

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