A nurse is preparing to assign tasks to an assistive personnel (AP). Which of the following tasks should the nurse assign to the AP?
Verifying placement of a nasogastric tube.
Evaluating a client's understanding of how to use crutches.
Replacing the gauze on a skin abrasion.
Monitoring bowel sounds.
The Correct Answer is C
Choice A rationale:
Verifying placement of a nasogastric tube requires specialized training and knowledge to ensure correct placement and prevent complications. The nurse should retain this task to ensure patient safety.
Choice B rationale:
Evaluating a client's understanding of how to use crutches involves assessing the client's comprehension and ability to use crutches safely and effectively. This task requires nursing judgment and should not be delegated to an assistive personnel.
Choice C rationale:
Replacing the gauze on a skin abrasion is a task that can be safely assigned to an assistive personnel. It involves basic wound care, which typically falls within the scope of practice for assistive personnel. The AP can be trained to follow established protocols for wound cleaning and dressing changes.
Choice D rationale:
Monitoring bowel sounds requires clinical judgment and the ability to recognize variations from the normal range. The nurse should perform this task, as it involves assessing the client's condition and making appropriate decisions based on the findings.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
Using a 5-mL syringe to flush the catheter is not the best choice. Central venous access devices typically require a larger syringe for flushing to prevent excessive pressure and potential damage to the catheter. A smaller syringe like the 5-mL syringe can create higher pressure, which could cause complications.
Choice B rationale:
Changing the site dressing and stabilization device every 24 hours is not the recommended practice. The dressing and stabilization device should be changed according to facility policy and as needed, but a rigid 24-hour schedule is not necessary and might increase the risk of infection due to unnecessary exposure.
Choice C rationale:
Expecting blood to appear in the catheter lumen after flushing is incorrect. Blood in the catheter lumen after flushing could indicate complications such as a dislodged catheter or other issues requiring immediate attention. The catheter should ideally remain patent without the presence of blood.
Choice D rationale:
This is the correct choice. Using chlorhexidine solution to clean the catheter is an evidence-based practice to prevent infection at the insertion site. Chlorhexidine has broad-spectrum antimicrobial properties and helps reduce the risk of catheter-related infections.
Correct Answer is C
Explanation
Choice A rationale:
Verifying placement of a nasogastric tube requires specialized training and knowledge to ensure correct placement and prevent complications. The nurse should retain this task to ensure patient safety.
Choice B rationale:
Evaluating a client's understanding of how to use crutches involves assessing the client's comprehension and ability to use crutches safely and effectively. This task requires nursing judgment and should not be delegated to an assistive personnel.
Choice C rationale:
Replacing the gauze on a skin abrasion is a task that can be safely assigned to an assistive personnel. It involves basic wound care, which typically falls within the scope of practice for assistive personnel. The AP can be trained to follow established protocols for wound cleaning and dressing changes.
Choice D rationale:
Monitoring bowel sounds requires clinical judgment and the ability to recognize variations from the normal range. The nurse should perform this task, as it involves assessing the client's condition and making appropriate decisions based on the findings.
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