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A nurse on a medical-surgical unit is delegating client care. Which of the following tasks should the nurse delegate to assistive personnel?

Instructing a client on self-administration of a tap water enema

Suctioning a client's long-term tracheostomy

Performing a dressing change on a client's peripherally inserted central catheter

Using a pain rating scale to monitor a client's pain level

Answer and Explanation

The Correct Answer is D

Rating the pain scale of a client is a low risk task that can be performed by assistive personnel

A. Self-administration of a tap water enema requires careful training which is the responsibility of a nurse

B. Suctioning a tracheostomy tube is a risky procedure within the scope of a registered nurse

C. Replacing a dressing is a procedure that requires infection control measures therefore a nursing intervention

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Correct Answer is C

Explanation

Measles is an airborne disease that requires use of N95 respirator before entry and removed after exiting the room with the isolated client/exam room.

A. Varicella clients should be isolated in a negative pressure room.

B. Influenza requires droplet precautions.

D. Masks are needed all the time irrespective of the distance.

A. A client who has a neck injury and is unable to breathe spontaneously B. A client who has bipolar disorder and is exhibiting signs of hallucination C. A client who has two open chest wounds with a left tracheal deviation D. A client who has major burns over 75% of her body surface area

Correct Answer is A

Explanation

The nurse should prioritize care based on the ABCs of basic life support. The client with neck injury likely has airway obstruction which poses immediate risk of death and should, therefore, be addressed first.

B. Client is exhibiting features of a psychiatric disorder which can be addressed later.

C. Client has issues with inadequate breathing which comes second after airway.

D. Client is likely to have circulatory issues due to dehydration secondary to skin losses.

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A nurse on a medical-surgical unit is delegating client care. Which of the following tasks should the nurse delegate to assistive personnel?

Nursing Test Bank

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