A 73-year-old male patient has been admitted to an inpatient unit from the emergency room. He has been coughing severely for the past two days, has a headache, and a sore throat.
His COVID test is positive and he has Type II Diabetes. He denies any history of smoking.
His vital signs are as follows: Temperature - 101.0, Pulse - 84, Respiration - 24, Blood Pressure - 152/84, Pulse oximetry - 92%. The registered nurse (RN) delegates the collection of a urine specimen and Fasting Blood Sugar (FSBS) from the client to the nurse aide II. What are the responsibilities of the RN in regard to this delegated task?
Select all that apply.
Ensure the nurse aide has the required training to perform these tasks.
Maintain accountability for ensuring the delegated tasks are conducted correctly and completely.
Ensure policies cover the delegation.
Perform an assessment of the patient prior to delegation.
Observe all tasks performed by the nurse aide II.
Correct Answer : A,B,C,D
Choice A rationale
The RN must ensure that the nurse aide has the required training to perform these tasks. This is because the RN is responsible for determining client needs and when to delegate. The RN must also ensure that the delegate is competent to perform the activity.
Choice B rationale
The RN must maintain accountability for ensuring the delegated tasks are conducted correctly and completely. This is because the RN is answerable for their own choices, decisions, and actions as measured against a standard.
Choice C rationale
The RN must ensure policies cover the delegation. This is because the RN must understand the delegation process and the state nurse practice act (NPA) to ensure that it is safely, ethically, and effectively carried out.
Choice D rationale
The RN must perform an assessment of the patient prior to delegation. This is because the RN’s decision of whether or not to delegate is based upon their judgement concerning the condition of the patient.
Choice E rationale
While observing all tasks performed by the nurse aide II is a good practice, it is not a requirement for the RN in regard to this delegated task.
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Related Questions
Correct Answer is D
Explanation
Choice A rationale
Insertion of a urinary catheter is a direct care intervention. It involves direct personal contact with the patient.
Choice B rationale
Reviewing discharge instructions with the client is also a direct care intervention. It involves direct personal contact with the patient.
Choice C rationale
Performing routine oral care is a direct care intervention. It involves direct personal contact with the patient.
Choice D rationale
Documentation of IV insertion is an example of an indirect care intervention. Indirect care interventions are performed when the nurse provides assistance in a setting other than with the patient. Examples of indirect care interventions are attending care conferences, documenting, and communicating about patient care with other providers.
Correct Answer is D
Explanation
Choice A rationale
Respiratory acidosis is characterized by a pH less than 7.35 and a PaCO2 greater than 454. In this case, the pH is 7.43, which is within the normal range, and the PaCO2 is 46, which is slightly above the normal range. Therefore, this does not indicate respiratory acidosis.
Choice B rationale
Respiratory alkalosis is characterized by a pH greater than 7.45 and a PaCO2 less than 354. In this case, the pH is 7.43, which is within the normal range, and the PaCO2 is 46, which is slightly above the normal range. Therefore, this does not indicate respiratory alkalosis.
Choice C rationale
Metabolic acidosis is characterized by a pH less than 7.35 and a HCO3 less than 224. In this case, the pH is 7.43, which is within the normal range, and the HCO3 is 35, which is above the normal range. Therefore, this does not indicate metabolic acidosis.
Choice D rationale
Metabolic alkalosis is characterized by a pH greater than 7.45 and a HCO3 greater than 264. In this case, the pH is 7.43, which is within the normal range, and the HCO3 is 35, which is above the normal range. Therefore, this indicates metabolic alkalosis.
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