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 C

Explanation

A. Inspect the preschooler's tonsils for edema.: While tonsil inspection might be part of a general assessment, in a child with suspected epiglottitis, inspecting the throat should be avoided as it can trigger airway obstruction or cause further distress.

B. Collect a sputum sample.: Sputum collection is not typically indicated for epiglottitis diagnosis. A rapid diagnosis is essential to ensure timely intervention, and sputum samples are not a key diagnostic tool for this condition.

C. Determine the preschooler's oxygen saturation level.: Epiglottitis can lead to significant airway obstruction, so monitoring the oxygen saturation level is critical to assess for hypoxia and ensure adequate oxygenation. Early intervention may be required to maintain the child's airway.

D. Obtain a specimen for throat culture.: A throat culture should not be obtained in suspected epiglottitis, as manipulating the throat could cause complete airway obstruction. Immediate intervention to secure the airway is the priority.

A. Give the client a straw to use for drinking. B. Place oral suction equipment next to the client's bedside. C. Provide thin liquids to help the client swallow. D. Use a needleless syringe to instill feedings.

Correct Answer is B

Explanation

A. "Give the client a straw to use for drinking" is incorrect. Straws are not recommended for clients with dysphagia because they can increase the risk of aspiration. It is better to use a cup to control the amount of liquid ingested and reduce choking risk.

B. "Place oral suction equipment next to the client's bedside" is correct. For clients with dysphagia, having oral suction equipment readily available can help clear the airway quickly in case of aspiration or choking. It is an important safety measure in the management of dysphagia.

C. "Provide thin liquids to help the client swallow" is incorrect. Thin liquids can increase the risk of aspiration for clients with dysphagia. It is often recommended to provide thickened liquids, as they are easier to swallow and less likely to be aspirated.

D. "Use a needleless syringe to instill feedings" is incorrect. The use of a needleless syringe for feeding is generally not appropriate for clients with dysphagia unless specifically recommended for feeding via a tube. Otherwise, feeding should be done carefully with consideration for the type and consistency of the food.

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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 the care of a preschooler who has manifestations that suggest epiglottitis. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

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Correct Answer is B

Explanation

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