A nurse in a long-term care facility is reinforcing teaching about safe delegation practices with a newly licensed nurse. Which of the following statements should the nurse include in the teaching?

"Delegate tasks such as vital signs regardless of the client's condition."

"Delegate simple tasks prior to evaluating the client's condition."

"Observe delegated tasks directly during task performance."

"Delegated tasks require follow-up to ensure compliance."

Answer and Explanation

The Correct Answer is D

Explanation:

A. "Delegate tasks such as vital signs regardless of the client's condition."

This statement is incorrect because delegation should be based on the complexity of the task, the client's condition and stability, the competence of the delegatee, and other factors. Vital signs are critical assessments that often require the direct involvement of a licensed nurse, especially when there are changes in the client's condition or if the client is unstable.

B. "Delegate simple tasks prior to evaluating the client's condition."

This statement is incorrect because delegation should not occur based solely on the simplicity of the task. Instead, the nurse should evaluate the client's condition first, assess the complexity of care required, and then delegate tasks accordingly. The client's needs, stability, and safety should guide the delegation process.

C. "Observe delegated tasks directly during task performance."

While direct observation of delegated tasks is important, it may not always be feasible or necessary for every task. Nurses should use their judgment to determine the level of supervision required based on factors such as the complexity of the task, the delegatee's experience and competence, and the client's condition. Direct observation may be necessary for more complex or critical tasks, but for routine and low-risk tasks, periodic checks and effective communication with the delegatee can suffice.

D. "Delegated tasks require follow-up to ensure compliance."

This statement is correct. Follow-up is essential to ensure that delegated tasks were performed correctly, safely, and in accordance with the client's care plan. It allows the nurse to verify task completion, assess the client's response if applicable, address any issues or concerns that arise, and provide feedback and guidance to the delegatee. Follow-up also helps maintain accountability and quality of care.

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Correct Answer is C

Explanation

Explanation:

A. Encourage the client to increase participation in community social activities:

While social activities can be beneficial for overall well-being, including mental and emotional aspects, at the end of life for a client with HIV, the focus shifts towards palliative care and symptom management. Encouraging social activities may not directly address the client's immediate end-of-life needs.

B. Prepare the client to begin highly active antiretroviral therapy (HAART):

Starting or continuing highly active antiretroviral therapy (HAART) may not be appropriate at the end of life. HAART is typically used to manage HIV infection and prolong life expectancy by controlling viral replication. However, at the end of life, the focus shifts towards comfort care rather than aggressive treatment aimed at extending life.

C. Provide routine analgesia to minimize episodes of breakthrough pain:

This intervention is more aligned with the principles of end-of-life care. Providing routine analgesia helps manage pain effectively, which is crucial for improving the client's comfort and quality of life during this stage.

D. Promote client weight gain of one to two pounds per week:

Weight gain may not be a priority at the end of life, especially if the client is experiencing advanced HIV disease or complications. Instead of focusing on weight gain, the emphasis should be on optimizing comfort, managing symptoms, and enhancing quality of life.

A. Arrange referral for family therapy to deal with home stressors. B. Follow the agency's guidelines for reporting suspected abuse. C. Check the bruises at the next visit to the client's home. D. Institute more frequent visits to the client's home.

Correct Answer is B

Explanation

Explanation:

A. Arrange referral for family therapy to deal with home stressors:

While family therapy may be beneficial for addressing home stressors, it is not the first step when there is a suspicion of physical abuse. The priority in cases of suspected abuse is to ensure the client's safety and to report the suspicion to the appropriate authorities.

B. Follow the agency's guidelines for reporting suspected abuse:

This is the correct action to take first. Nurses are mandated reporters, and they must follow their agency's protocols and legal requirements for reporting suspected abuse. Reporting ensures that the client's situation is investigated promptly, and appropriate interventions are implemented to protect the client.

C. Check the bruises at the next visit to the client's home:

Delaying action and waiting until the next visit to check the bruises is not appropriate in cases of suspected abuse. Immediate action is necessary to address the safety of the client. Suspected abuse should be reported promptly to the relevant authorities for investigation.

D. Institute more frequent visits to the client's home:

Increasing the frequency of visits may not address the immediate safety concerns of the client if abuse is suspected. While increased monitoring may be necessary in certain situations, reporting the suspicion of abuse and initiating appropriate interventions should take precedence.

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A nurse in a long-term care facility is reinforcing teaching about safe delegation practices with a newly licensed nurse. Which of the following statements should the nurse include in the teaching?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is contributing to the plan of care for a client who has had HIV for 10 years and is at the end of life. Which of the following interventions should the nurse recommend?

Correct Answer is C

Explanation

Correct Answer is B

Explanation

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A nurse in a long-term care facility is reinforcing teaching about safe delegation practices with a newly licensed nurse. Which of the following statements should the nurse include in the teaching?

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