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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C","D"]
Explanation
A. Stop the transfusion. The first action is to stop the transfusion to prevent further fluid overload.
B. Place the client in high-Fowler's position. This position reduces venous return to the heart and improves breathing and oxygenation.
C. Obtain a prescription for a diuretic. Diuretics (e.g., furosemide) help remove excess fluid, relieving pulmonary congestion and reducing strain on the heart.
D. Administer oxygen to the client. Oxygen helps relieve hypoxia caused by fluid buildup in the lungs.
E. Administer epinephrine to the client. Epinephrine is used for anaphylactic reactions, not circulatory overload. There is no indication of an allergic reaction in this scenario.
Correct Answer is A
Explanation
A. Request a referral for an occupational therapist. An occupational therapist (OT) can help the client maintain independence by teaching adaptive techniques and providing assistive devices for ADLs, such as dressing, bathing, and eating.
B. Request a home health aide to perform the client's ADLs for them. While a home health aide can assist with ADLs, the goal is to promote independence, not to have someone do everything for the client.
C. Instruct family members to place the client in a nursing home. Placement in a nursing home is a complex decision based on multiple factors. The nurse should focus on interventions to support the client at home before considering long-term care.
D. Contact the client's pharmacy to change their medication doses. Nurses do not have the authority to change medication doses. Medication adjustments should be discussed with the prescribing provider if needed.
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