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 A
Explanation
A. Consider gender and age when selecting an interpreter Cultural preferences may influence comfort and communication. For example, a client may feel more comfortable speaking with an interpreter of the same gender or age group.
B. Direct comments and questions to the interpreter The nurse should speak directly to the client, not the interpreter, to maintain engagement and respect.
C. Speak to the client in a loud voice Speaking louder does not improve comprehension and may come off as disrespectful. Clear, slow speech is more effective.
D. Ask a member of the client's family to serve as an interpreter Family members may omit or alter information and are not trained in medical terminology or confidentiality laws. A professional medical interpreter should be used.
Correct Answer is D
Explanation
A. "You should wear a sterile gown when outside of your room." While protective clothing may be required in certain cases, wearing a sterile gown outside the room is not a standard recommendation for immunocompromised clients.
B. "You'll share a room with a client who is also immunocompromised." Clients who require a protective environment should be placed in a private room to minimize the risk of exposure to infections.
C. "You are required to wear an N95 respirator mask." N95 respirators are typically required for healthcare workers caring for clients with airborne precautions, not for immunocompromised clients in a protective environment.
D. "You will be placed in a positive-pressure airflow room." A positive-pressure room helps keep airborne pathogens out by ensuring that air flows out of the room rather than into it, reducing the risk of infections.
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