A nurse is making client care assignments for an assistive personnel (AP). Which of the following tasks should the nurse assign to the AP?

Inspect the incision of a client who is postoperative following a leg amputation.

Evaluate the need to suction the airway of a client who has a new tracheostomy.

Complete postmortem care for a client who has died.

Feed a client who has difficulty swallowing liquids following a stroke.

Answer and Explanation

The Correct Answer is C

A. Inspect the incision of a client who is postoperative following a leg amputation is incorrect. Inspecting an incision requires clinical assessment to identify signs of infection, dehiscence, or other complications, which should be performed by a licensed nurse.

B. Evaluate the need to suction the airway of a client who has a new tracheostomy is incorrect. Suctioning the airway of a client with a tracheostomy is a skilled task that requires assessment of the airway and airway management, which should be performed by a nurse.

C. Complete postmortem care for a client who has died is correct. Postmortem care, such as cleaning and preparing the body, is a task that can be delegated to an AP. The AP should not be involved in clinical assessments but can perform routine care under supervision.

D. Feed a client who has difficulty swallowing liquids following a stroke is incorrect. Feeding a client with swallowing difficulties requires careful monitoring and risk assessment for aspiration, which is outside the scope of tasks that can be delegated to an AP without proper training.

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Correct Answer is D

Explanation

A. Positive clonus is a sign of hyperreflexia and can indicate worsening preeclampsia or severe central nervous system irritability. It is not a therapeutic effect of magnesium sulfate.

B. Urinary output 20 mL/hr is below the minimum expected urine output (which is generally 30 mL/hr). This finding suggests oliguria and may be a sign of worsening renal function, which is not a therapeutic effect of magnesium sulfate.

C. Respiratory rate 10/min is too low. Magnesium sulfate can cause respiratory depression, and a respiratory rate of 10/min may indicate toxicity. This is not a therapeutic effect.

D. Deep tendon reflexes 2+ is the correct answer. Magnesium sulfate is used to prevent seizures in preeclampsia by acting as a CNS depressant. A normal response of 2+ for deep tendon reflexes indicates that magnesium sulfate is having a therapeutic effect and the client is not experiencing magnesium toxicity (which would typically cause a decreased reflex response..

A. "I can take antacids at the same time as this medication." B. "I have to take this medication on an empty stomach." C. "I should expect to have diarrhea while taking this medication." D. "I will need to remain upright for 1 hour after taking the medication."

Correct Answer is B

Explanation

A. "I can take antacids at the same time as this medication.": This is incorrect. Pantoprazole is a proton pump inhibitor (PPI), and taking antacids at the same time can interfere with the medication's effectiveness. It is generally recommended to space out antacids and PPIs by at least 1 hour.

B. "I have to take this medication on an empty stomach.": This is correct. Pantoprazole should be taken on an empty stomach, typically 30 minutes before breakfast, to optimize absorption and effectiveness.

C. "I should expect to have diarrhea while taking this medication.": Diarrhea is not a common side effect of pantoprazole. While side effects such as headache, nausea, and abdominal pain are more common, diarrhea is not typically expected.

D. "I will need to remain upright for 1 hour after taking the medication.": This is incorrect. While it is generally advised to remain upright for a period after taking medications like bisphosphonates, it is not required for pantoprazole. The main instruction for pantoprazole is to take it on an empty stomach before eating.

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A nurse is making client care assignments for an assistive personnel (AP). Which of the following tasks should the nurse assign to the AP?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is collecting data from a client who is receiving magnesium sulfate via continuous IV infusion to treat preeclampsia. Which of the following findings indicates that the medication is having a therapeutic effect?

Correct Answer is D

Explanation

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Correct Answer is B

Explanation

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