A nurse delegates a task to an assistive personnel (AP) who refuses to complete the task. Which of the following actions should the nurse take first?

Plan time to complete the task.

Assign the task to another AP.

Notify the charge nurse immediately.

Discuss the AP's concerns about the task.

Answer and Explanation

The Correct Answer is D

Rationale:

A. Plan time to complete the task: While the nurse may need to complete the task if it remains undone, doing so without first addressing the AP’s refusal overlooks a potential communication or training issue and does not resolve the underlying problem.

B. Assign the task to another AP: Reassigning the task without understanding the reason for refusal may perpetuate noncompliance and disrupt team dynamics. It is important to first clarify why the AP is unwilling before redirecting the task.

C. Notify the charge nurse immediately: Escalating to the charge nurse is appropriate if the issue cannot be resolved directly. However, the first action should be to attempt communication and resolution with the AP to encourage accountability and collaboration.

D. Discuss the AP's concerns about the task: This is the most appropriate initial response. By opening a discussion, the nurse can identify whether the refusal stems from a misunderstanding, lack of training, or legitimate concern, allowing for timely correction or education.

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Correct Answer is B

Explanation

Rationale:

A. Changing a sterile dressing on a client's open wound: Sterile procedures require nursing judgment and knowledge of aseptic technique. This task falls within the scope of practice for licensed nurses, not assistive personnel.

B. Performing postmortem care for a client: Postmortem care, such as cleaning the body and preparing it for transport, is a non-sterile, routine task that can be safely delegated to assistive personnel in accordance with facility policy and under nurse supervision.

C. Interpreting a client's laboratory values: Interpretation of lab results requires clinical judgment and is the responsibility of licensed personnel. Assistive personnel are not trained or authorized to interpret clinical data.

D. Inserting a client's NG tube: Inserting a nasogastric tube is an invasive procedure that requires assessment and verification of placement. This task is beyond the scope of assistive personnel and should be performed by a nurse.

A. Decreased skin turgor B. Sensation of tingling C. Diminished capillary refill D. Pale-colored toes E. Pain relieved by analgesia

Correct Answer is ["B","C","D"]

Explanation

Rationale:

A. Decreased skin turgor: Decreased skin turgor is a sign of dehydration or fluid imbalance and is not related to compartment syndrome. It does not reflect changes in perfusion or nerve compression caused by increased compartment pressure.

B. Sensation of tingling: Tingling or paresthesia is an early sign of nerve compression due to rising pressure within a muscle compartment. It indicates compromised nerve function and is a key symptom of evolving compartment syndrome.

C. Diminished capillary refill: Delayed or diminished capillary refill suggests impaired perfusion. In a newly placed cast, this can indicate increased pressure restricting blood flow—an early and critical sign of compartment syndrome.

D. Pale-colored toes: Pallor in the extremities is a sign of decreased arterial blood flow. Pale-colored toes after cast placement suggest compromised circulation, which is consistent with compartment syndrome.

E. Pain relieved by analgesia: Pain that is unrelieved by analgesia especially pain out of proportion to the injury is a hallmark of compartment syndrome. Pain that is relieved by medication does not indicate compartment syndrome and may reflect expected postoperative discomfort.

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A nurse delegates a task to an assistive personnel (AP) who refuses to complete the task. Which of the following actions should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in a long-term care facility is making client care assignments for the unit. Which of the following tasks should the nurse assign to an assistive personnel?

Correct Answer is B

Explanation

A nurse is monitoring a client's lower extremity following the placement of a cast earlier in the day. Which of the following findings should the nurse identify as manifestations of compartment syndrome? (Select all that apply.)

Correct Answer is ["B","C","D"]

Explanation

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