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 B

Explanation

A. Use humor to decrease tension: Humor may not translate well across cultures and languages, and it can lead to miscommunication or offend the client unintentionally. It is better to maintain a respectful, clear, and professional communication style when using an interpreter.

B. Speak in short sentences: Using short, clear sentences helps the interpreter accurately convey the nurse’s message to the client. It allows for better understanding and avoids overwhelming the interpreter with complex information that could get misinterpreted.

C. Speak in third person: Speaking in third person can cause confusion and distance the nurse from the client. It is best to speak directly to the client using first and second person ("I" and "you") so the interaction feels more personal and respectful.

D. Talk directly to the interpreter: The nurse should always speak directly to the client, maintaining eye contact and body language with the client. The interpreter is there to facilitate communication, not to replace the direct interaction between the nurse and the client.

A. Clamp the urinary catheter tubing. B. Replace the indwelling urinary catheter with a smaller diameter catheter C. Irrigate the bladder with 20 to 30 mL of 0.9% sodium chloride irrigation D. Allow the tubing to hang below the drainage bag

Correct Answer is C

Explanation

A. Clamp the urinary catheter tubing: Clamping the catheter tubing is not appropriate because it can lead to bladder distention, increased pressure, and risk of bladder rupture. Maintaining continuous drainage is essential to prevent complications following prostate surgery.

B. Replace the indwelling urinary catheter with a smaller diameter catheter: Replacing the catheter is not the first intervention when clots and dark red blood are present. Smaller diameter catheters would actually be less effective in clearing clots and could worsen the blockage.

C. Irrigate the bladder with 20 to 30 mL of 0.9% sodium chloride irrigation: Manual irrigation helps to clear clots that may be obstructing the catheter, promoting continued drainage and reducing the risk of bladder distention. Gentle irrigation is the appropriate first step to manage clot formation.

D. Allow the tubing to hang below the drainage bag: The drainage tubing should always be positioned above the collection bag to maintain gravitational drainage. Letting the tubing hang below the bag would impair drainage and could lead to backflow and infection.

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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

Naxlex Comprehensive Predictor Exams

A nurse is using the assistance of an interpreter to reinforce discharge teaching to a client who does not speak the same language as the nurse. Which of the following actions should the nurse plan to take when working with an interpreter?

Correct Answer is B

Explanation

A nurse is caring for a client who has continuous bladder irrigation following a transurethral resection of the prostate. The nurse notes clots and dark red blood in the catheter collection bag. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

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