A nurse on a medical-surgical unit is assigning tasks to an assistive personnel (AP). Which of the following tasks should the nurse delegate to the AP?
Performing indwelling urinary catheter care
Demonstrating how to use an incentive spirometer
Measuring the depth of a stage 3 pressure injury
Changing the appliance on a new colostomy
The Correct Answer is A
Delegating tasks involves assigning appropriate responsibilities to assistive personnel based on their level of training, competency, and scope of practice. Performing indwelling urinary catheter care is a task that can be safely delegated to an AP who has received proper training and demonstrated competency in this skill. The nurse should ensure that the AP is familiar with the facility's policies and procedures regarding catheter care and can perform the task safely and effectively.
Demonstrating how to use an incentive spirometer requires specialized knowledge and the ability to provide clear instructions. It is typically within the scope of practice of licensed healthcare professionals, such as nurses or respiratory therapists, who have the necessary expertise to properly educate and guide patients in using an incentive spirometer. This task should not be delegated to an AP.
Measuring and assessing the depth of a pressure injury requires clinical judgment and accurate evaluation, which falls within the scope of practice of a licensed nurse. It involves understanding wound assessment, proper technique for measuring depth, and interpreting the findings. This task should be performed by the nurse rather than an AP.
Changing the appliance on a new colostomy involves skills such as assessing the stoma, selecting the appropriate appliance, and ensuring proper application. This task requires specialized knowledge and training in stoma care, and it should be performed by a licensed nurse who has the expertise in managing ostomies. It should not be delegated to an AP.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Answer: A. Frequently remind the client of the expectations for her behavior.
Rationale:
A) Frequently remind the client of the expectations for her behavior:
Clients experiencing mania may have difficulty maintaining appropriate behavior due to their heightened energy levels and impulsivity. Frequently reminding them of behavioral expectations helps provide structure and boundaries, which can promote a safer and more controlled environment.
B) Encourage the client to participate in a group activity in the dayroom:
While social interaction can be beneficial, clients in a manic state might be overly stimulated by group activities. This can exacerbate their symptoms, leading to increased agitation or disruptive behavior. It's often more appropriate to provide a calm and low-stimulation environment.
C) Allow the client to pick her own choice of clothing:
Allowing a manic client to choose their own clothing can lead to choices that are inappropriate for the setting or the weather, as judgment may be impaired during mania. Providing guidance in clothing choices can help ensure the client is dressed suitably and safely.
D) Encourage the client to increase physical activity during the day:
While physical activity is generally beneficial, clients in a manic state may already be overly active and may not need encouragement to increase their activity. Overexertion can lead to exhaustion and further exacerbate manic symptoms. It is often more beneficial to encourage activities that promote relaxation and calmness.
Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"C"}
Explanation
Compartment syndrome occurs when there is increased pressure within a closed muscle compartment, leading to reduced blood flow to the muscles and nerves in that compartment. In this case, the open fracture and subsequent reduction and stabilization procedure can cause swelling and increased pressure within the affected compartment. This can impede blood flow and potentially lead to tissue damage. Common symptoms include severe pain, swelling, numbness, and decreased or absent pulses. Immediate medical attention is necessary if compartment syndrome is suspected.
Deep Vein Thrombosis (DVT) refers to the formation of blood clots within the deep veins, typically in the lower extremities. In the case of a client with an open fracture and immobilization with a splint, the risk of DVT increases due to factors such as reduced mobility, injury to blood vessels, and blood stasis. DVT can lead to serious complications if a clot dislodges and travels to the lungs, causing a pulmonary embolism. Symptoms of DVT may include pain, swelling, warmth, and redness in the affected limb.
While osteomyelitis and fat embolism syndrome can occur as complications of long bone fractures, they are not explicitly mentioned in the given scenario. Osteomyelitis refers to an infection in the bone, which can develop if bacteria enter an open fracture. Fat embolism syndrome can occur when fat globules from the bone marrow enter the bloodstream, usually following a long bone fracture.
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