A nurse on a medical-surgical unit is planning care for four clients. Which of the following tasks should the nurse delegate to an assistive personnel (AP)?
Administering a rectal suppository for a client who has postoperative constipation.
Instructing a postoperative client to use an incentive spirometer.
Measuring blood glucose using a monitor for a client who has diabetic ketoacidosis.
Using a pulse oximeter to measure oxygen saturation for a client who is ready for discharge.
The Correct Answer is D
Choice A rationale: Administering a rectal suppository is a medication administration task that should be performed by a licensed nurse, not delegated to an assistive personnel.
Choice B rationale: Instructing a client to use an incentive spirometer involves providing education and ensuring proper technique, which falls within the scope of practice of a licensed nurse.
Choice C rationale: Measuring blood glucose for a client with diabetic ketoacidosis involves monitoring a critical condition and interpreting results, which should be done by a licensed nurse.
Choice D rationale: Using a pulse oximeter to measure oxygen saturation is a simple and routine task that can be delegated to an assistive personnel for a stable client who is ready for discharge.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The correct answer is Choice A.
Choice A rationale: Placing a sterile kit on the overbed table above waist level maintains the sterility of the field. This position ensures that the kit is not contaminated by lower surfaces or inadvertent touch, which is essential for preventing infection during dressing changes.
Choice B rationale: Opening the outermost flap of the sterile kit toward their body increases the risk of contaminating the sterile field. The first flap should be opened away from the body to maintain the sterility of the field and prevent contamination.
Choice C rationale: Turning their back to the sterile field when coughing is incorrect because it increases the risk of contamination. The nurse should step away from the sterile field and cough into their elbow or use a mask to maintain sterility.
Choice D rationale: Holding a package of sterile gauze 30.5 cm (12 in) above the sterile field when dropping the gauze onto the field is too high and increases the risk of contamination. The gauze should be held closer, approximately 6 inches above the field, to ensure accuracy and sterility.
Correct Answer is ["A","B","C","E"]
Explanation
Choice A rationale:
Before initiating teaching for a client with a new diagnosis of type 2 diabetes mellitus, it is essential to identify the client's learning needs. This involves assessing what the client already knows about the condition, their level of understanding, and any specific areas of concern or interest. By establishing the learning needs, the nurse can tailor the teaching plan to address the client's individual requirements, thereby enhancing the effectiveness of the education provided.
Choice B rationale:
While determining the client's literacy level (Choice B) is important, it might not take precedence over understanding the client's learning needs. However, assessing literacy is still relevant because it helps the nurse adapt the teaching materials and language used to ensure the client comprehends the information.
Choice C rationale:
Evaluating the client's readiness for learning (Choice C) is significant, but it should ideally follow the identification of learning needs. Readiness for learning pertains to the client's emotional and psychological state, which can impact their ability to absorb new information. While essential, it should not be the initial step in planning teaching.
Choice D rationale:
Verifying the client's computer access (Choice D) is not directly related to the immediate planning of teaching for a new diagnosis of type 2 diabetes mellitus. While technology and access to online resources can enhance learning, this consideration is secondary to understanding the client's knowledge gaps and preferred learning style.
Choice E rationale:
Identifying the client's learning style (Choice E) is valuable in customizing the teaching approach, but it comes after establishing learning needs. Learning styles, such as visual, auditory, or kinesthetic, can influence the most effective way to present information. However, without first determining what the client needs to know, tailoring the teaching style might not yield optimal results.
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