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. Arms raised above her head with her legs elevated on pillows: This is not an appropriate position for a lumbar puncture. The positioning is not ideal for access to the lumbar region and would be uncomfortable for the client.

B. Prone with her arms at her side and her legs extended: While this position may be used for certain procedures, it is not the most appropriate position for a lumbar puncture, which requires specific spinal positioning to access the subarachnoid space effectively.

C. Trendelenburg with her body in Sims' position: Trendelenburg involves positioning the client with the head lower than the feet, which is not necessary for a lumbar puncture and could interfere with the procedure. The Sims' position is more suited for certain other procedures.

D. Head flexed to the chest and her knees pulled up to the abdomen: This is correct. The client should be in a fetal position, with the head flexed toward the chest and the knees pulled up toward the abdomen. This position helps to widen the intervertebral spaces and facilitates easier access for the lumbar puncture.

A. The client should use a hair dryer on a warm setting to relieve itching inside the cast. B. The client's extremity should be elevated after the cast is applied. C. The client can shower with the cast after 24 hr. D. The client should keep the cast covered until it is dry.

Correct Answer is B

Explanation

A. The client should use a hair dryer on a warm setting to relieve itching inside the cast is incorrect. Using a hair dryer could cause skin burns or damage the cast. Additionally, the client should avoid introducing moisture into the cast, which could lead to skin irritation or infection.

B. The client's extremity should be elevated after the cast is applied is correct. Elevating the extremity helps reduce swelling and inflammation during the initial phase after cast application. It is important to elevate the limb above the level of the heart to promote venous return and reduce swelling.

C. The client can shower with the cast after 24 hr is incorrect. The plaster cast should not get wet. The nurse should instruct the client to keep the cast dry at all times. A plastic cover or cast protector should be used when showering to prevent moisture from seeping into the cast.

D. The client should keep the cast covered until it is dry is incorrect. It is true that the cast should be kept dry, but keeping it covered is not enough. The primary concern is preventing moisture and ensuring the plaster cast is allowed to air dry in a well-ventilated area without getting wet.

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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 D

Explanation

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Correct Answer is B

Explanation

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