A charge nurse is making client care assignments. Which of the following tasks should the nurse delegate to assistive personnel (AP)? (Select all that apply.)
Assist a client to ambulate using a gait belt.
Review a low-sodium diet for a client who has hypertension.
Feed a client who had a stroke 3 months ago.
Bathe a client who had an amputation 2 days ago.
Expllain oral hygiene to a client receiving chemotherapy.
Correct Answer : A,C,D
Rationale A: Assisting a client to ambulate using a gait belt is a task within the scope of practice for assistive personnel. It involves physical support and monitoring, which do not require the advanced training of a registered nurse. This task ensures the client's safety while promoting mobility.
Rationale B: Reviewing a low-sodium diet is not within the scope of practice for assistive personnel as it requires nutritional knowledge and the ability to teach, which are responsibilities of a registered nurse or a dietitian.
Rationale C: Feeding a client who had a stroke 3 months ago can be delegated to assistive personnel. This task does not require the clinical judgment of a nurse and can be performed following a predefined plan of care.
Rationale D: Bathing a client who had an amputation 2 days ago can be delegated to assistive personnel. They are trained to assist with activities of daily living, including bathing, while ensuring the client's safety and comfort.
Rationale E: Explaining oral hygiene to a client receiving chemotherapy involves patient education and understanding of the specific needs related to the client's condition, which are beyond the role of assistive personnel. This task requires the expertise of a nurse or other healthcare professional.
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Related Questions
Correct Answer is D
Explanation
A. After removal of an indwelling urinary catheter, it is common for a client to experience urinary frequency for a few days. This is due to the bladder readjusting to its normal function.
B. Blood-tinged urine may occur after catheter removal, but it is not an expected outcome. It should be assessed and reported if it occurs.
C. Highly concentrated urine is not typically an expected outcome after catheter removal.
It may indicate dehydration or another issue that should be addressed.
D. Temporary urinary retention can occur after catheter removal, especially in older adults. This is why it's important to monitor the client for signs of retention, such as discomfort, restlessness, or a palpable bladder.
Correct Answer is A
Explanation
A. Gloves should be removed first. This is because the gloves are the items most likely to be contaminated. To remove gloves, grasp the outside edge near the wrist and peel them off, turning them inside out as you go.
B. The gown should be removed next. The gown protects the nurse's clothing from contamination. Untie or unfasten the gown, and then carefully remove it, taking care to avoid touching the outside of the gown.
C. Face shields or goggles should be removed next if used. This helps protect the eyes and face. Handle the shield or goggles by the headband or earpieces and remove them without touching the front.
D. Mask should be removed last. The mask helps protect the respiratory system. Untie or unhook the mask from behind the ears or head and discard it.
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