A nurse is planning care for a client who has had a stroke, resulting in aphasia and dysphagia. Which of the following tasks should the nurse assign to an assistive personnel (AP)? (Select all that apply.)

Assist the client with a partial bed bath.

Measure the client's BP after the nurse administers an antihypertensive medication.

Test the client's swallowing ability by providing thickened liquids.

Use a communication board to ask what the client wants for lunch.

Irrigate the client's indwelling urinary catheter.

Answer and Explanation

Correct Answer : A,B

A. Assist the client with a partial bed bath: Assisting with personal hygiene is within the scope of practice for assistive personnel (AP). This task does not require nursing judgment or assessment skills, making it appropriate to delegate while ensuring the client’s comfort and dignity are maintained.

B. Measure the client's BP after the nurse administers an antihypertensive medication: Taking vital signs is a standard task that APs can perform. The nurse is responsible for administering the medication and interpreting the results, while the AP can obtain the blood pressure reading and report it promptly to the nurse for assessment of the client’s response.

C. Test the client's swallowing ability by providing thickened liquids: Assessing swallowing is a nursing responsibility because it requires professional judgment to identify signs of aspiration, evaluate dysphagia severity, and implement safe feeding techniques. Delegating this task could risk the client’s safety if aspiration occurs.

D. Use a communication board to ask what the client wants for lunch: Determining the client’s preferences using a communication board requires assessment of cognitive and language abilities and may involve interpreting nonverbal cues. This is a nursing task that involves critical thinking and cannot be safely delegated to an AP.

E. Irrigate the client's indwelling urinary catheter: Catheter irrigation is considered an invasive procedure that carries risks of infection and requires knowledge of sterile technique. This task is within the nurse’s scope of practice and should not be delegated to APs, as improper technique could cause harm.

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Correct Answer is A

Explanation

A. Ambulating a client who is postoperative: Ambulation is an appropriate task to delegate to assistive personnel when the client is stable and the activity does not require nursing assessment or clinical judgment. The nurse must first assess the client’s readiness and provide clear instructions, after which the AP can safely assist with walking to promote circulation, prevent deep vein thrombosis, and improve recovery.

B. Inserting an indwelling urinary catheter for a client: Urinary catheter insertion is an invasive sterile procedure that requires clinical skill and knowledge of aseptic technique. It also involves assessment of indications, monitoring for complications, and evaluating urine output. These responsibilities fall within the scope of licensed nursing practice.

C. Demonstrating the use of an incentive spirometer to a client: Initial teaching about therapeutic devices requires nursing knowledge and the ability to assess the client’s understanding and respiratory status. Demonstrating and educating the client about incentive spirometer use is part of the nurse’s role in promoting lung expansion and preventing postoperative complications.

D. Confirming that a client's pain has decreased after receiving an analgesic: Evaluating a client’s response to medication involves clinical assessment and judgment. Pain reassessment after analgesic administration determines the effectiveness of treatment and guides further interventions. Tis evaluation is part of the nursing process, it must be performed by the nurse.

A. The tube aspirate has a pH of 7 (less than 5). B. An x-ray shows the end of the tube above the pylorus. C. Bowel sounds are present on auscultation. D. The client reports relief of nausea.

Correct Answer is B

Explanation

A. The tube aspirate has a pH of 7 (less than 5): Gastric aspirate typically has an acidic pH ranging from about 1 to 5 due to the presence of hydrochloric acid in the stomach. A pH of 7 is neutral and more consistent with respiratory or intestinal secretions rather than gastric contents. Therefore, this finding does not reliably confirm that the NG tube is correctly positioned in the stomach.

B. An x-ray shows the end of the tube above the pylorus: Radiographic confirmation is considered the gold standard for verifying nasogastric tube placement. An x-ray showing the tube tip located within the stomach, above the pylorus, confirms that the tube has not entered the respiratory tract and is positioned appropriately for gastric decompression or feeding. This method provides the most accurate and reliable confirmation of placement.

C. Bowel sounds are present on auscultation: The presence of bowel sounds only indicates intestinal motility and does not provide information about the position of the NG tube. Historically, auscultating for air insufflation (“whooshing” sound) was used to check placement, but this practice is unreliable because similar sounds can occur even when the tube is misplaced in the lungs.

D. The client reports relief of nausea: Symptom relief may occur after gastric decompression but does not confirm correct placement of the tube. A client might experience temporary relief even if the tube is partially misplaced. Objective verification methods such as radiographic confirmation are necessary to ensure safe and correct tube positioning.

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A nurse is planning care for a client who has had a stroke, resulting in aphasia and dysphagia. Which of the following tasks should the nurse assign to an assistive personnel (AP)? (Select all that apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to delegate client care tasks to an assistive personnel (AP). Which of the following tasks should the nurse delegate?

Correct Answer is A

Explanation

A nurse has just inserted a nasogastric (NG) tube for a client. Which of the following findings should the nurse expect to confirm correct tube placement?

Correct Answer is B

Explanation

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