A nurse is planning client care for herself and an assistive personnel (AP) working with her. Which of the following tasks should the nurse plan to perform?
Assisting a client to cough and deep breathe
Application of antiembolic stockings
Administration of an enema
Assessing a client's sacrum for edema
The Correct Answer is D
Rationale:
A. Assisting a client to cough and deep breathe is a task that can be performed by an AP under supervision.
B. Application of antiembolic stockings is within the scope of APs, though it may be monitored by an RN.
C. Administration of an enema typically requires nursing judgment and assessment, making it more appropriate for the RN.
D. Assessing a client’s sacrum for edema requires clinical assessment skills and nursing judgment, which should be performed by an RN.
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Correct Answer is D
Explanation
Rationale:
A. Reassuring the partner is important for emotional support but does not directly impact the immediate safety of clients.
B. Reinforcing a dressing is important for wound care but does not address urgent concerns.
C. Taking a telephone prescription is necessary but not as immediate as addressing a potential complication.
D. Assessing a client with unilateral calf pain is the priority as it may indicate a serious condition such as deep vein thrombosis (DVT), which requires immediate evaluation and intervention.
Correct Answer is C
Explanation
Rationale:
A. Asking about discharge is a general inquiry that does not require immediate follow-up unless it’s related to specific discharge planning.
B. Changing the dressing is a routine postoperative care task and doesn’t necessarily require follow-up unless there’s a concern about the procedure.
C. Not receiving medications is a critical issue that needs immediate attention to address potential gaps in treatment.
D. Not knowing how to use the remote control is a minor issue that does not require clinical follow-up.