A charge nurse is making shift assignments on a medical-surgical unit. Which of the following tasks should the nurse assign to the AP?

Measuring oxygen saturation for a client who has dyspnea

Performing nasal hygiene for a client who has an NG tube

Pouching a client's ostomy bag for a new colostomy

Inserting a rectal suppository for a client who is vomiting

Answer and Explanation

The Correct Answer is C

a.   Measuring oxygen saturation requires nursing judgment and assessment skills, which are beyond the scope of practice for an assistive personnel (AP).
b.   Nasal hygiene for a client with an NG tube involves specific skills and requires nursing assessment to ensure proper technique and patient comfort.
c.   Pouching a client's ostomy bag involves routine care that can be safely performed by assistive personnel under the direction and supervision of a nurse.
d.   Inserting a rectal suppository requires nursing judgment and assessment to determine appropriateness based on the client's condition, which is beyond the scope of practice for an AP.

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Correct Answer is D

Explanation

A. A client refusing care from assistive personnel of the opposite gender is important and must be handled to respect the client's preferences, but it does not immediately impact the overall functioning of the unit or client safety. This situation can be addressed after the staffing issue.

B. No transport assistance being available for a client to go to physical therapy is a logistical issue that can be resolved with alternative arrangements, such as rescheduling the therapy or finding different personnel for transport. It is not a critical priority compared to staffing shortages.

C. A heated disagreement between two nurses over a scheduling issue is a team dynamic problem that requires attention, but it is not urgent enough to affect patient safety or unit operations in the immediate term. Resolving staffing shortages takes precedence.

D. Addressing the absence of three staff members is critical as it directly affects patient care and safety. A shortage in staff can lead to unsafe working conditions, delays in client care, and an increased risk of errors. Ensuring adequate staffing is the highest priority in this situation

A. Close the documentation program on the computer B. Find out which staff member left the documentation program on the screen C. Tell the charge nurse that the visitor viewed a client’s protected health information D. Inform the visitor that client records are confidential

Correct Answer is A

Explanation

A. Closing the documentation program on the computer is the most immediate action to prevent further unauthorized access to protected health information (PHI). It directly addresses the breach of confidentiality and limits potential damage.

B. While it is important to identify the staff member responsible for leaving the program open, this does not immediately address the current breach of confidentiality. This action would be a subsequent step after securing the PHI.

C. Notifying the charge nurse is an important step in the process of addressing the breach. However, it is not the first action to take as it does not prevent further exposure of the PHI.

D. Informing the visitor about the confidentiality of client records is necessary, but it is not the first action to take. The priority is to secure the PHI before addressing the visitor's behavior.

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A charge nurse is making shift assignments on a medical-surgical unit. Which of the following tasks should the nurse assign to the AP?

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Naxlex Comprehensive Predictor Exams

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