36: A nurse is delegating care for a group of four clients. Which of the following tasks should the nurse delegate to an assistive person?
Irrigate and perform a dressing change for a client who has a pressure injury wound.
Obtain a daily weight on a client who has heart failure.
Teach the use of an incentive spirometer to a postoperative client.
Administer oral PRN pain medication to a client who has arthritis.
The Correct Answer is B
A. Irrigate and perform a dressing change for a client who has a pressure injury wound: This task requires specialized knowledge and skill, particularly in wound care management. It involves assessing the wound, choosing appropriate dressings, and monitoring for signs of infection, which are beyond the scope of duties for assistive personnel.
B. Obtain a daily weight on a client who has heart failure: This task is suitable for delegation to an assistive person because it is a routine, non-invasive procedure that does not require clinical judgment or assessment. It helps in monitoring the client's condition, especially in heart failure management.
C. Teach the use of an incentive spirometer to a postoperative client: Teaching involves educating the client on the proper technique and benefits of using the device, which requires nursing judgment and the ability to address questions or concerns. This task should be performed by a nurse.
D. Administer oral PRN pain medication to a client who has arthritis: Administering medications involves evaluating the client’s pain level, assessing potential side effects, and ensuring the correct medication is given, which requires a nurse’s clinical judgment and knowledge.
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Related Questions
Correct Answer is C
Explanation
A. Acute pain manifested by client's report: This diagnosis is too general and does not address the specific issue of unknown etiology or the need for further investigation.
B. Acute pain related to psychosomatic condition: This diagnosis assumes a psychosomatic cause without sufficient evidence. The cause of the pain is not yet clear, so this may not be accurate.
C. Acute pain related to unknown etiology: This diagnosis accurately reflects the situation of pain with an unclear cause and is appropriate for guiding further assessment and investigation.
D. Acute pain related to unknown factors: This diagnosis is vague and less specific than "unknown etiology," which provides a clearer framework for understanding the cause of the pain.
Correct Answer is A
Explanation
A. Use soap and water to clean the client's perineum: Correct. Using soap and water is the standard method for cleaning the perineum to ensure it is effectively cleaned while maintaining hygiene.
B. Use the same section of washcloth for each area cleaned: Incorrect. To prevent cross-contamination, the nurse should use a clean section of the washcloth or a new washcloth for each area cleaned.
C. Allow the client's perineum to air dry: Incorrect. The perineum should be gently patted dry with a clean towel to prevent irritation and ensure proper drying.
D. Start at the client's rectum and clean to the client's perineum: Incorrect. The proper technique is to clean from the perineum to the rectum to prevent the spread of bacteria from the rectal area to the vaginal area.
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