A nurse in a long-term care facility is delegating care for a group of clients for the oncoming shift. Which of the following tasks should the nurse delegate to an assistive personnel? (Select all that apply.)
Plan care for a client who has dysphagia.
Transfer a client who is receiving radiation therapy to radiology.
Record urine output for a client who has a suprapubic catheter
Measure vital signs for a client who requires contact precautions.
Correct Answer : B,C,D
A. Planning care, especially for a client with dysphagia (difficulty swallowing), involves assessment, evaluation, and critical thinking, which are within the scope of practice for licensed nurses, not APs. This task should not be delegated to an AP.
B. Transferring a client, especially one undergoing radiation therapy, often involves understanding specific precautions and handling techniques. This task is generally within the scope of APs, provided they have proper training and understand any specific precautions related to the client's condition.
C. Recording urine output is ataskthat can be delegated to an assistive personnel under the supervision of a registerednurse, as they do not require nursing judgment or assessment skills.
D. Measuring vital signs is a taskthat can be delegated to an assistive personnel under the supervision of a registered nurse, as they do not require nursing judgment or assessment skills.
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Correct Answer is D
Explanation
The correct answer is D.
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Correct Answer is B
Explanation
The correct answer is B.
Stop the infusion. The nurse should stop the infusion immediately to prevent further fluid accumulation and tissue damage. This is a priority action accordingto the ABCDE principle, which guides nurses to prioritize airway, breathing, circulation, disability, and exposure issues. Infiltration is a complication of IV therapy that occurs when fluid leaks into the surrounding tissue due to dislodgment or puncture of the catheter. The signs and symptoms of infiltration include edema, coolness, pallor, pain, and decreased flow rate at the insertion site.
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