A nurse on a medical-surgical unit has just received a change-of-shift report for four clients. Which of the following tasks should the nurse assign to an assistive personnel?
Showing a client who has a new colostomy how to empty the pouch.
Reinserting an NG tube for a client who requires gastric decompression
Performing a closed catheter irrigation for a client who is postoperative
Bathing a client who has hemiparesis following a stroke
The Correct Answer is D
A. Showing a client who has a new colostomy how to empty the pouch. Client education requires the clinical knowledge and teaching skills of a nurse.
B. Re-inserting an NG tube for a client who requires gastric decompression. NG tube insertion is a skilled task that requires clinical assessment and monitoring by a nurse.
C. Performing a closed catheter irrigation for a client who is postoperative. Closed catheter irrigation requires sterile technique and clinical judgment, which are nursing responsibilities.
D. Bathing a client who has hemiparesis following a stroke. APs can assist with bathing and hygiene tasks.
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Related Questions
Correct Answer is A
Explanation
A. Observe the client's verbal and nonverbal behaviors. Observing nonverbal cues helps assess understanding and emotional responses when there is a language barrier.
B. Ask the client's adolescent child to act as an interpreter. Family members, especially minors, should not interpret due to confidentiality and potential inaccuracies.
C. Avoid the use of gestures. Gestures can be helpful when used appropriately, though cultural considerations are necessary.
D. Speak directly to the interpreter. The nurse should speak directly to the client, even when an interpreter is present, to maintain rapport and respect.
Correct Answer is D
Explanation
A. Cover the site with a stockinette dressing: This action may help secure the IV site but does not immediately address the safety concern.
B. Administer a sedative: Administering sedatives is not the first-line intervention and requires a provider's order.
C. Apply a soft mitten restraint: Restraints should be the last resort after implementing less restrictive measures. Closer observation and attempts to redirect the client are less restrictive and should be tried first.
D. Place the client close to the nurses' station: Proximity allows for frequent monitoring, preventing further self-harm.
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