Which of the following may a nursing assistant be responsible for ...

[newyorker26]

Which of the following may a nursing assistant be responsible for determining?
 
  a. Vital signs
  b. Cranial nerve function
  c. Neck vein distention
  d. Auscultation of bowel sounds

Question 2

The nurse evaluates that further teaching is required if, during digital removal of feces, the new staff nurse:
 
  A. Provides perianal skin care
  B. Continues the procedure if bleeding starts
  C. Follows the procedure by offering the client the bedpan
  D. Discontinues the procedure in the presence of bradycardia

[verrinzo]

Answer to Question 1

A
Assistive personnel can be trained to count apical pulse and peripheral pulses after the nurse's initial assessment. Assistive personnel need to be instructed to recognize temperature and color changes, along with changes in peripheral pulses. Comprehensive heart and neck vessel assessment should not be delegated to assistive personnel. However, assistive personnel should know to report the development of abdominal pain or changes in the patient's bowel habits or dietary intake.

Answer to Question 2

B

B. Assess anal and perianal region for source of bleeding. Stop if bleeding is excessive.
A. Observe for the presence of perianal skin irritation. Presence of such indicates the need for postprocedure skin care to the perianal region to reduce pain during subsequent bowel elimination.
D. The sacral branch of the vagus nerve is stimulated during digital stimulation; this stimulation may result in reflex slowing of heart rate.

[newyorker26]

Thanks

[verrinzo]

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