A charge nurse is delegating tasks for a group of clients on a medical surgical unit. Which of the following tasks should the nurse delegate to the assistive personnel?
Educate a client about the purpose of a sputum specimen.
Perform irrigation of an indwelling urinary catheter.
Administer liquid aspirin to a client who is crying.
Provide a bed bath for a client who requires isolation precautions.
The Correct Answer is D
A. Educate a client about the purpose of a sputum specimen: Client education requires nursing knowledge and judgment to explain procedures, answer questions, and evaluate understanding. This cannot be delegated to assistive personnel.
B. Perform irrigation of an indwelling urinary catheter: Catheter irrigation is a sterile invasive procedure that requires nursing skill to prevent infection and complications. It falls outside the scope of assistive personnel.
C. Administer liquid aspirin to a client who is crying: Medication administration involves assessment, calculation, and monitoring for adverse effects, which are responsibilities of a licensed nurse. Assistive personnel cannot administer medications.
D. Provide a bed bath for a client who requires isolation precautions: Assisting with hygiene is within the scope of assistive personnel. They can safely provide a bed bath while following isolation protocols under the supervision of the nurse.
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Related Questions
Correct Answer is D
Explanation
Rationale:
A. Asks the client what her plans are for follow-up care: This is an appropriate action that demonstrates concern for the client’s continuity of care and safety, even if she decides to leave against medical advice.
B. Asks the client to sign a form releasing the hospital from legal responsibility: This is standard practice when a client leaves against medical advice, as it documents that the client was informed of potential risks and chose to leave voluntarily.
C. Shows the client her abnormal laboratory results: Providing relevant medical information is appropriate to help the client make an informed decision about her care before leaving the facility.
D. Asks security to detain the client until the provider is notified: Clients have the legal right to leave a healthcare facility unless they are under specific legal or mental health holds. Detaining a competent adult against their will is unlawful and violates patient rights.
Correct Answer is C
Explanation
Rationale:
A. Check the compatibility of cefazolin with the client's existing IV fluids: Compatibility is important to prevent precipitation or inactivation of the drug, but it should be done only after confirming the medication is safe for the client to receive.
B. Assess the IV for patency: Ensuring the IV line is patent is necessary before administration to avoid infiltration or extravasation, but it is not the first priority when preparing a first-time antibiotic dose.
C. Review the client's allergy history: Reviewing allergies is the first and most critical step, as cefazolin is a cephalosporin that can cause severe allergic reactions, particularly in clients with a history of beta-lactam (e.g., penicillin) allergy. Administering the drug without this check could cause life-threatening anaphylaxis.
D. Obtain the reconstituted antibiotic from the pharmacy: Securing the medication from the pharmacy is part of preparation, but this should only occur after confirming it is safe for the client to receive based on allergy status.
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