A charge nurse is making staff assignments on a medical-surgical unit. Which of the following tasks should the nurse plan to delegate to an assistive personnel?

Pouching a client's ostomy bag for a new colostomy

Performing nasal hygiene for a client who has an NG tube

Measuring oxygen saturation for a client who has dyspnea

Inserting a rectal suppository for a client who is vomiting

Answer and Explanation

The Correct Answer is B

A.   Pouching a client's ostomy bag for a new colostomy requires specialized training and should typically be performed by a nurse.
B.   Performing nasal hygiene for a client with an NG tube involves basic hygiene tasks that can be safely delegated to an assistive personnel after proper training and supervision.
C.   Measuring oxygen saturation for a client who has dyspnea requires a basic skill that can be delegated to an assistive personnel.
D.   Inserting a rectal suppository for a vomiting client involves a nursing task that should be performed by a nurse due to the client's condition and the nature of the task.

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Correct Answer is B

Explanation

A. Notifying risk management before initiating treatment is not necessary in this emergent situation; patient care should take precedence.
B. In emergent situations where a patient lacks decision-making capacity and requires
immediate treatment to prevent harm, consent for treatment can be assumed based on the principle of implied consent.
C. Contacting the client's next of kin for consent might delay necessary treatment for the disoriented and arrhythmic client, which could be harmful.
D. Having the client sign a consent for treatment might not be feasible or appropriate if the client is disoriented and lacks decision-making capacity in an emergency situation.

A. A client who has an open fracture of the femur B. A client who has periorbital ecchymosis C. A client who has a deep partial thickness burn on the lower extremities D. A client who has an asymmetrical thorax

Correct Answer is D

Explanation

Rationale for A: An open fracture of the femur is serious and requires prompt treatment, but it does not typically indicate an immediate life threat compared to other conditions.

Rationale for B: Periorbital ecchymosis can indicate facial trauma, but it is not necessarily life-threatening and would not be prioritized as emergent.

Rationale for C: A deep partial thickness burn on the lower extremities is significant and requires treatment, but unless the burn covers a large area or is complicated by other factors, it is not the most critical issue compared to respiratory or cardiovascular threats.

Rationale for D: An asymmetrical thorax may suggest a possible pneumothorax or other significant respiratory issue, which could lead to respiratory distress or failure. This client should be tagged as emergent due to the potential for rapid deterioration.

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A charge nurse is making staff assignments on a medical-surgical unit. Which of the following tasks should the nurse plan to delegate to an assistive personnel?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is D

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