A nurse is planning assignments for the upcoming shift. Which of the following tasks should the nurse delegate to an assistive personnel? (Select all that apply.)

Instruct a client on the use of an incentive spirometer.

Insert an NG tube for a client who requires enteral feedings.

Obtain a client's vital signs every 4 hr.

Record a client's intake after each meal,

Transfer a client to physical therapy.

Answer and Explanation

Correct Answer : C,D,E

C. Obtain a client's vital signs every 4 hr:
This task can typically be delegated to assistive personnel (AP) who have been trained and deemed competent in measuring vital signs. Routine monitoring of vital signs, such as temperature, pulse, respirations, and blood pressure, is within the scope of practice for AP and does not require the specialized skills of a licensed nurse.

D. Record a client's intake after each meal:
Assistive personnel can be delegated the task of recording a client's intake after each meal. This involves documenting the amount and type of food and fluids consumed by the client. While assessment of intake may involve some judgment, AP can be trained to perform this task accurately and consistently.

E. Transfer a client to physical therapy:
Assistive personnel can assist with transferring clients to physical therapy sessions. This may include tasks such as assisting clients into a wheelchair or onto a stretcher and accompanying them to the therapy area. While ensuring client safety during transfers is crucial, AP can perform these tasks under the direction and supervision of licensed nursing staff or physical therapists.

A. Instruct a client on the use of an incentive spirometer:
Teaching clients how to use medical equipment, such as an incentive spirometer, typically requires specialized knowledge and skills that fall within the scope of practice of licensed nursing staff. Therefore, this task should not be delegated to assistive personnel.

B. Insert an NG tube for a client who requires enteral feedings:
Inserting an NG tube is a specialized nursing skill that requires training, expertise, and an understanding of anatomy, proper technique, and potential complications. This task should only be performed by licensed nursing staff, such as registered nurses (RNs) or licensed practical nurses (LPNs), who have received appropriate education and training.

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Correct Answer is D

Explanation

A. Occupational therapist: While occupational therapy may be beneficial for some aspects of managing sciatica, such as ergonomic assessments and activities of daily living modifications, a referral to an occupational therapist is not typically indicated specifically for the use of a TENS unit.
B. Chiropractor: Chiropractic care involves manual adjustments of the spine and other joints, which may provide relief for some individuals with sciatica. However, a referral to a chiropractor is not necessary solely for the use of a TENS unit.
C. Acupuncturist: Acupuncture is a complementary therapy that involves the insertion of thin needles into specific points on the body to relieve pain and promote healing. While acupuncture may be considered as part of a comprehensive treatment plan for sciatica, it is not typically associated with the use of a TENS unit.
D. Physical therapist: Physical therapy plays a crucial role in the management of sciatica. A physical therapist can provide tailored exercises, stretches, and modalities such as TENS therapy to alleviate pain, improve mobility, and strengthen muscles. Therefore, a referral to a physical therapist is appropriate for a client with sciatica who has a prescription for a TENS unit. The physical therapist can assess the client's condition, educate them on the proper use of the TENS unit, and integrate it into their overall treatment plan.

A. Obtain urinary samples by disconnecting the tubing connections. B. Secure the catheter to the client's thigh. - C. Keep the urinary bag at bladder level when ambulating. D. Loop the tubing so that it is lower than the collection bag. E. Loop the tubing so that it is lower than the collection bag.

Correct Answer is B

Explanation

A. Obtain urinary samples by disconnecting the tubing connections:
This action increases the risk of contamination and introduces bacteria into the urinary system, potentially leading to UTIs. Urine samples should be obtained using a sterile technique to minimize the risk of infection.

B. Secure the catheter to the client's thigh:
Securing the catheter to the client's thigh can cause tension and traction on the catheter, increasing the risk of urethral trauma and introducing bacteria into the urinary tract. Catheters should be secured without tension to prevent damage to the urethra and reduce the risk of UTIs.

C. Keep the urinary bag at bladder level when ambulating:
Keeping the urinary bag at bladder level when ambulating prevents urine from flowing back into the bladder, reducing the risk of UTIs. Gravity drainage helps maintain the flow of urine and prevents stasis, which can contribute to bacterial growth and UTIs.

D. Loop the tubing so that it is lower than the collection bag:
Looping the tubing so that it is lower than the collection bag creates a dependent loop where urine can accumulate, increasing the risk of bacterial colonization and UTIs. The tubing should be kept straight and free of kinks to ensure continuous drainage and prevent urine from pooling in the tubing.

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A nurse is planning assignments for the upcoming shift. Which of the following tasks should the nurse delegate to an assistive personnel? (Select all that apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is planning care for a client who has sciatica and a prescription for a transcutaneous electrical nerve stimulation (TENS) unit. Which of the following referrals should the nurse anticipate for this client?

Correct Answer is D

Explanation

A nurse is planning care for a client who has a history of urinary tract infections (UTIs) and requires placement of an indwelling urinary catheter. Which of the following actions should the nurse take to help minimize the client's risk for acquiring a UTI?

Correct Answer is B

Explanation

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