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 B

Explanation

A. "Your baby needs to suck on a pacifier" is not necessarily the best advice for this situation. While pacifiers can help some babies self-soothe, crying is often a sign of an unmet need, and further assessment is needed to determine the cause of the crying. Offering a pacifier without addressing other potential causes might overlook the root issue.

B. "Swaddling your baby snugly in a blanket might help soothe her" is correct. Swaddling can help calm a newborn by providing a sense of security and warmth, mimicking the conditions of the womb. It is a common technique used to soothe babies.

C. "Breastfed babies are usually fussy from swallowing too much air during feedings" is incorrect. While some babies may have mild gas or discomfort from swallowing air, excessive crying is not typically due to this alone, especially if the baby has been fed properly and burped.

D. "Breastfed babies often need to be supplemented with formula" is not appropriate. While some breastfeeding difficulties can occur, advising formula supplementation without further investigation could undermine the breastfeeding process and should only be suggested after careful assessment and if truly necessary.

A. Encourage the client to soak in a hot bath. B. Instruct the client to change positions frequently. C. Apply fundal pressure during contractions. D. Tell the client to push during contractions.

Correct Answer is B

Explanation

A. Encourage the client to soak in a hot bath.: While a warm bath can help alleviate muscle tension and discomfort, it is not recommended during the latent phase of labor due to the potential for increasing the risk of infection, especially if the membranes are ruptured.

B. Instruct the client to change positions frequently.: Frequent position changes during the latent stage of labor can help alleviate pelvic pain, improve comfort, and encourage progress in labor. This is a beneficial intervention that promotes movement and comfort without introducing unnecessary risks.

C. Apply fundal pressure during contractions.: Fundal pressure is not appropriate during the latent stage of labor, as it can cause fetal distress or other complications. It is typically avoided unless indicated in more advanced stages of labor under specific circumstances.

D. Tell the client to push during contractions.: Pushing is not recommended during the latent stage of labor. The latent phase involves the cervix gradually dilating, and pushing should be delayed until the active stage of labor when the cervix is fully dilated and ready for delivery.

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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

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Correct Answer is B

Explanation

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Correct Answer is B

Explanation

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