A nurse on a medical-surgical unit is teaching a newly licensed nurse about tasks to delegate to assistive personnel (AP). Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?
"An AP may monitor the peripheral IV insertion site of a client who is receiving replacement fluids."
"An AP may count the respirations of a client who is going to have surgery later the same day."
"An AP may take orthostatic blood pressure measurements from a client who reports dizziness."
"An AP may perform a central line dressing change for a client who is ready for discharge."
The Correct Answer is B
A. "An AP may monitor the peripheral IV insertion site of a client who is receiving replacement fluids." –
Monitoring IV sites requires assessment skills and clinical judgment, which are within the scope of a licensed nurse, not assistive personnel.
B. "An AP may count the respirations of a client who is going to have surgery later the same day." –
Counting respirations is a basic task within the AP’s scope of practice. However, the nurse is responsible for interpreting the findings.
C. "An AP may take orthostatic blood pressure measurements from a client who reports dizziness." –
Measuring orthostatic blood pressure requires critical thinking and assessment of the client’s condition, which falls under the nurse’s responsibilities.
D. "An AP may perform a central line dressing change for a client who is ready for discharge." –
Performing a central line dressing change is a sterile procedure that requires nursing assessment and should be completed by a licensed nurse.
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Related Questions
Correct Answer is C
Explanation
A. "A client was placed in the waiting room based on their triage assessment." Hospitals can prioritize clients based on triage assessment as long as they receive a medical screening examination and stabilizing treatment if necessary.
B. "A client was transferred to the inpatient antepartum unit to rule out preterm labor." EMTALA requires that hospitals evaluate and stabilize clients with emergency medical conditions, including preterm labor. Transferring a client within the same facility for further evaluation does not violate EMTALA.
C. "A client was referred to the county hospital for medical screening evaluation." Under EMTALA, hospitals must provide a medical screening examination and necessary stabilizing treatment before referring or transferring a client, regardless of their insurance status. Sending a client elsewhere for evaluation without treatment is a violation.
D. "A stable client was transferred to a public hospital that provides reduced-cost care." Once a client has been stabilized, hospitals may arrange for transfer to another facility, provided the transfer meets EMTALA guidelines and is in the client's best interest.
Correct Answer is A
Explanation
A. "I will hold my cane on my stronger side." The cane should be held on the stronger (unaffected) side to provide better support and stability while allowing the weaker leg to move more freely.
B. "I should hold my cane 12 inches from my side." The cane should be positioned about 6–10 inches to the side of the foot to ensure proper balance and support.
C. "I will keep my elbow flexed at a 90-degree angle while moving my cane." The elbow should be flexed at about 15–30 degrees, not 90 degrees, to maintain comfort and proper control of the cane.
D. "I should move my weaker leg before moving my cane." The correct sequence is to move the cane first, then move the weaker leg forward, followed by the stronger leg, which provides better stability and reduces fall risk.
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