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 C
Explanation
The correct answer is C. Open the outermost flap of the sterile kit away from the nurse's body.
Rationale: The nurse should open the outermost flap of the sterile kit away from their body first, as this will prevent contamination of their clothing or hands by touching any part of
the inside surface or contents of the kit. The nurse should then open each side flap by grasping only its outer edge and pulling it toward them. The nurse should then open the flap nearest to them by grasping only its outer edge and pulling it toward them. The nurse should then apply sterile gloves before touching any part of the inside surface or contents of the kit.
Correct Answer is D
Explanation
The correct answer is D. Semi-Fowler's position. This position allows for optimal drainage of secretions and reduces edema and tension on the suture line. It also facilitates breathing and prevents aspiration. Left lateral, dorsal recumbent, and supine positions can increase the risk of airway obstruction, bleeding and infection.
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