A patient requires repositioning every 2 hours. Which task can the nurse delegate to the nursing assistive personnel?
Identifying immobility hazards
Determining the level of comfort
Changing the patient's position
Assessing circulation
The Correct Answer is C
A. Identifying immobility hazards requires clinical judgment and assessment skills that are beyond the scope of nursing assistive personnel.
B. Determining the level of comfort is a subjective assessment that should be done by a nurse to ensure accurate interpretation of the patient’s condition.
C. Changing the patient's position can be safely delegated to nursing assistive personnel, as it is a straightforward task that does not require advanced clinical judgment.
D. Assessing circulation involves evaluating the patient's vital signs and other parameters, which should be performed by a nurse to ensure comprehensive care and assessment.
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Correct Answer is ["B","C","D","E","F"]
Explanation
A. This statement is incorrect; the nurse should touch only the inside of the first glove while putting it on to maintain sterility.
B. The outer glove package should be removed by tearing it open to access the gloves inside.
C. After putting on the second glove, interlocking hands helps to ensure that the gloves remain sterile.
D. Slipping fingers underneath the second glove cuff with the gloved dominant hand helps to keep the gloves sterile while donning them.
E. Laying the glove package on a clean flat surface above the waistline prevents contamination.
F. The dominant hand should be gloved first to maintain a sterile technique, as the dominant hand is used for the procedure.
Correct Answer is C
Explanation
A. Continuing with the injection after seeing blood return increases the risk of injecting into a blood vessel, which is not safe for IM injections.
B. Administering at a slower rate does not address the issue of possible intravascular injection.
C. If blood is aspirated, the correct procedure is to withdraw the needle, dispose of the medication, and prepare a new dose to prevent intravascular administration, as IM injections are meant to be given into muscle tissue, not into a vein.
D. Pulling the needle back slightly is not recommended because it does not ensure that the needle is completely out of the blood vessel.