A nurse in an acute care setting is planning care for a group of clients at the beginning of the shift. Which of the following tasks should the nurse assign to the assistive personnel (AP)?
Removal of the nasogastric tube of a client who has been receiving enteral feedings
Monitoring vital signs of a client who had an appendectomy 12 hr ago
Application of antibiotic ointment to the arm of a client who has dermatitis
Obtaining medical history information from a stable client who is being admitted
The Correct Answer is B
Rationale:
A. Removal of the nasogastric tube is a more complex task that typically requires the nurse’s assessment and judgment.
B. Monitoring vital signs is within the scope of tasks that can be assigned to assistive personnel. This task involves routine observation and does not require complex decision-making.
C. Application of antibiotic ointment requires specific knowledge about the condition and treatment, which is generally performed by a nurse.
D. Obtaining medical history information is a task that requires clinical judgment and interaction, and should be done by a nurse rather than an assistive personnel.
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Correct Answer is D
Explanation
Rationale:
A. A client who has a small circular partial-thickness burn of the left calf requires care, but this is less urgent compared to severe airway or respiratory issues.
B. A client who has a massive head injury and is experiencing seizures is critical but still less urgent compared to immediate life-threatening airway issues.
C. A client who has a splinted open fracture of left medial malleolus requires care but is not as immediately life-threatening as respiratory issues.
D. A client who has severe respiratory stridor and a deviated trachea has a life-threatening airway obstruction that needs immediate intervention to ensure adequate breathing and oxygenation.
Correct Answer is C
Explanation
Rationale:
A. "I had strep throat about one year ago" is not directly related to contraindications for glyburide.
B. "I got my flu shot at the pharmacy two weeks ago" does not affect the use of glyburide.
C. "I plan to continue nursing my baby until he is at least a year old" indicates a contraindication because glyburide is not recommended for use during breastfeeding due to potential effects on the infant.
D. "I am allergic to shellfish" is not relevant to the contraindications for glyburide.