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

Ambulating a client who is postoperative

Inserting an indwelling urinary catheter for a client

Demonstrating the use of an incentive spirometer to a client

Confirming that a client's pain has decreased after receiving an analgesic

Answer and Explanation

The Correct Answer is A

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.

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Correct Answer is B

Explanation

A. Bend at the waist: Bending at the waist while lifting places excessive strain on the lumbar spine and increases the risk of back injury. Proper lifting technique requires bending at the knees and hips while keeping the back straight to distribute the weight more safely across the larger leg muscles.

B. Stand close to the cabinet when lifting it: Standing close to the object reduces leverage and minimizes the force on the lower back. Keeping the load near the body maintains balance, improves control, and decreases the risk of musculoskeletal injury, making this a key ergonomic principle for safe lifting.

C. Use the back muscles for lifting: Lifting primarily with the back muscles increases the risk of strain or injury to the lumbar region. Instead, the nurse should engage the strong muscles of the legs and gluteal region to perform the lift safely while keeping the back aligned.

D. Keep the feet close together: Keeping the feet close together reduces stability and balance while lifting. A proper stance requires feet shoulder-width apart to provide a broad base of support, allowing safe weight transfer and reducing the risk of falls or musculoskeletal injury.

A. “I have been weighing myself every other morning." B. “I am trying to decrease my intake of foods with potassium." C. "I am limiting my sodium intake to 2 grams daily." D. "I am eating fewer potato chips and more fruit for snacks." E. "I lie down and rest after meals." F. "I know to call my doctor if I gain 3 pounds or more in 2 days."

Correct Answer is ["C","D","F"]

Explanation

A. “I have been weighing myself every other morning." Daily weight monitoring is essential in clients with heart failure because rapid weight gain may indicate fluid retention and worsening cardiac function. Weighing every other day can delay recognition of fluid accumulation. Clients should weigh themselves every morning at the same time to detect early changes in fluid status.

B. “I am trying to decrease my intake of foods with potassium." Potassium intake is not routinely restricted in heart failure unless the client has hyperkalemia or specific medication considerations. Many heart failure medications, such as loop diuretics, can cause potassium loss, and potassium intake may need to be maintained or increased depending on laboratory values.

C. "I am limiting my sodium intake to 2 grams daily." Sodium restriction is a key component of heart failure management because excess sodium promotes water retention and increases circulating blood volume. Limiting sodium intake to approximately 2 grams per day helps reduce fluid overload, decrease edema, and improve symptoms such as shortness of breath.

D. "I am eating fewer potato chips and more fruit for snacks." Processed snack foods such as potato chips contain high amounts of sodium, which contributes to fluid retention and worsening heart failure symptoms. Replacing these foods with fresh fruits reduces sodium intake and supports better nutritional habits, helping manage fluid balance and cardiovascular health.

E. "I lie down and rest after meals." Lying down immediately after eating can increase venous return and exacerbate dyspnea in clients with heart failure. Clients are generally encouraged to remain in a semi-upright position after meals to reduce cardiac workload and improve breathing. Rest periods are helpful, but positioning should avoid lying flat directly after eating.

F. "I know to call my doctor if I gain 3 pounds or more in 2 days." Rapid weight gain in heart failure often reflects fluid retention rather than increased body mass. A gain of approximately 2–3 pounds in 24 hours or 5 pounds in a week is recommended to notifying the provider. Early reporting allows adjustment of medications such as diuretics to prevent worsening heart failure.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is lifting a bedside cabinet to move it closer to a client who is sitting in a chair. To prevent self-injury, which of the following actions should the nurse take when lifting this object?

Correct Answer is B

Explanation

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Correct Answer is ["C","D","F"]

Explanation

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