A nurse is planning care for a client who is 1 day postoperative following abdominal surgery.
Which of the following tasks should the nurse delegate to an assistive personnel?
Transferring the client from the bed to a chair.
Checking the client’s surgical dressing for bleeding.
Determining whether the client has incisional pain.
Showing the client how to use an incentive spirometer.
The Correct Answer is A
Transferring the client from the bed to a chair. This is a task that can be delegated to an assistive personnel because it does not require nursing judgment or assessment. The nurse should provide clear instructions and supervise the assistive personnel during the transfer.
Choice B is wrong because checking the client’s surgical dressing for bleeding is a nursing assessment that requires clinical judgment and cannot be delegated.
The nurse should monitor the dressing for signs of infection, drainage, or dehiscence.
Choice C is wrong because determining whether the client has incisional pain is a nursing assessment that requires communication and evaluation skills and cannot be delegated.
The nurse should assess the client’s pain level, location, quality, and duration and administer pain medication as prescribed.
Choice D is wrong because showing the client how to use an incentive spirometer is a nursing intervention that requires teaching and evaluation skills and cannot be delegated.
The nurse should instruct the client on how to use the device to promote lung expansion and prevent atelectasis.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Proteinuria is the presence of excess protein in the urine, which is a hallmark of nephrotic syndrome. Nephrotic syndrome is a kidney disorder that causes increased permeability of the glomerular basement membrane, leading to loss of protein and other substances in the urine.
Choice B is wrong because hypolipidemia is a low level of lipids in the blood, which is not expected in nephrotic syndrome. On the contrary, nephrotic syndrome causes hyperlipidemia, which is a high level of lipids in the blood, due to increased synthesis and decreased clearance of lipoproteins.
Choice C is wrong because hyperalbuminemia is a high level of albumin in the blood, which is not expected in nephrotic syndrome. On the contrary, nephrotic syndrome causes hypoalbuminemia, which is a low level of albumin in the blood, due to loss of albumin in the urine and decreased synthesis by the liver.
Choice D is wrong because increased hemoglobin is not expected in nephrotic syndrome. On the contrary, nephrotic syndrome can cause anemia, which is a low level of hemoglobin in the blood, due to loss of iron and erythropoietin in the urine and decreased production of red blood cells by the bone marrow.
Normal ranges for proteinuria are less than 150 mg per day or less than 10 mg per deciliter on a random urine sample. Normal ranges for serum lipids are total cholesterol less than 200 mg per deciliter, LDL cholesterol less than 100 mg per deciliter, HDL cholesterol more than 40 mg per deciliter for men and more than 50 mg per deciliter for women, and triglycerides less than 150 mg per
deciliter. Normal ranges for serum albumin are 3.5 to 5.0 grams per deciliter.
Correct Answer is D
Explanation
The nurse should determine if the client has prepared their advance directives, which are legal documents that specify the client’s wishes regarding medical care in case they become incapacitated. Advance directives can include a living will, a durable power of attorney for health care, or a do-not-resuscitate order. The nurse should respect the client’s autonomy and right to self-determination by asking about their advance directives and ensuring that they are documented and followed.
Choice A is wrong because the nurse should not delay the admission while the client fills out the facility’s advance directives form.
The client has the right to refuse or accept any treatment, including filling out an advance directives form.
The nurse should inform the client about the benefits of having advance directives, but should not coerce or pressure them to complete one.
Choice B is wrong because the nurse should not confirm with the client’s family that the consent form has been signed.
The consent form is a legal document that indicates that the client has given informed consent for the surgery, which means that they have received adequate information about the procedure, its risks and benefits, and alternative options.
The consent form should be signed by the client, unless they are a minor, mentally incompetent, or unable to communicate.
The nurse should verify that the consent form has been signed by the client or their legal representative before the surgery.
Choice C is wrong because the nurse should not explain to the client that signing the facility’s consent form means they cannot refuse care.
Signing the consent form does not waive the client’s right to withdraw consent at any time before or during the surgery.
The nurse should inform the client that they can change their mind and refuse care at any point, and that their decision will be respected and honored.
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