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. "Check the client's skin every 4 hr" is incorrect. Skin checks should be performed more frequently for clients who are immobilized, ideally every 2 hours, to detect early signs of pressure damage and prevent the development of pressure ulcers.

B. "Place a donut-shaped cushion under the client" is incorrect. Donut-shaped cushions can increase pressure on the surrounding tissue, leading to ischemia and an increased risk of pressure ulcers. They are not recommended for ulcer prevention.

C. "Turn the client every/hr" is incorrect. The client should be repositioned regularly, but turning the client every hour is not a standard practice. The typical guideline is every 2 hours for clients at risk of pressure ulcers.

D. "Place the client in a 30° lateral position" is correct. The 30° lateral position helps to reduce pressure on bony prominences, such as the sacrum and heels, and is effective in preventing pressure ulcers. This position minimizes pressure on the skin while promoting circulation.

A. This medication will increase the immunity of your newborn. B. This medication will decrease the risk of hemorrhage in your newborn. C. This medication will decrease the possibility of your newborn developing jaundice. D. This medication will increase the absorption of nutrients in the intestines.

Correct Answer is B

Explanation

A. This medication will increase the immunity of your newborn.: Vitamin K does not directly affect the immunity of a newborn. It plays a crucial role in blood clotting, not immune function.

B. This medication will decrease the risk of hemorrhage in your newborn.: Vitamin K is given to newborns to prevent bleeding or hemorrhagic disease, as newborns have low levels of vitamin K at birth, which is essential for clotting.

C. This medication will decrease the possibility of your newborn developing jaundice.: Vitamin K does not have a role in preventing jaundice, which is related to elevated bilirubin levels in the blood.

D. This medication will increase the absorption of nutrients in the intestines.: Vitamin K does not influence nutrient absorption in the intestines; it primarily supports blood clotting by helping in the synthesis of clotting factors.

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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 assisting with developing a plan of care for a client who is immobilized. Which of the following interventions should the nurse recommend to reduce the development of pressure ulcers?

Correct Answer is D

Explanation

A nurse is preparing a vitamin K injection to give to a newborn. The newborn's mother questions the purpose of the medication. Which of the following responses should the nurse make?

Correct Answer is B

Explanation

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