A nurse is assigning care for four clients. Which of the following tasks should the nurse plan to delegate to an assistive personnel (AP)?

Instruct a client how to take their blood pressure.

Administer subcutaneous medications to a client.

Determine a client's intake and output.

Provide a status update to a client's family member.

Answer and Explanation

The Correct Answer is C

The correct answer is Choice C.

Choice A rationale:

Instructing a client on how to take their blood pressure is a task that involves providing education to the client on a non-invasive procedure that they can perform independently. However, this task requires a certain level of knowledge and understanding that an assistive personnel (AP) may not possess. Therefore, it is not the best task to delegate to an AP.

Choice B rationale:

Administering subcutaneous medications to a client is a task that requires a high level of skill and knowledge. It involves understanding the medication, its side effects, and the correct administration technique. This is a task that should be performed by a nurse or a healthcare professional with the appropriate training and licensure. Delegating this task to an AP could potentially put the client’s health at risk.

Choice C rationale:

Determining a client’s intake and output is a task that can be delegated to an AP. This task does not require the use of the nursing process and is within the range of function of an AP. It involves measuring and recording the amount of fluid a client consumes and excretes, which is a task that an AP is capable of performing.

Choice D rationale:

Providing a status update to a client’s family member is a task that requires a high level of discretion and understanding of the client’s condition. It involves communicating sensitive information about the client’s health status, which should be done by a nurse or a healthcare professional with the appropriate training and licensure. Delegating this task to an AP could potentially lead to miscommunication or a breach of the client’s privacy.

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Correct Answer is D

Explanation

The correct answer is choice D.

Choice A rationale:

“Auscultate the client’s bowel sounds.” While auscultating bowel sounds can provide information about the client’s gastrointestinal function, it is not the priority assessment for a client who has been vomiting and experiencing diarrhea for the past 6 hours.

Choice B rationale:

“Measure the client’s temperature.” Measuring the client’s temperature can help identify if the client has an infection, which could be causing the vomiting and diarrhea. However, it is not the priority assessment in this situation.

Choice C rationale:

“Check the client’s urine specific gravity.” Checking the client’s urine specific gravity can provide information about the client’s hydration status. However, it is not the priority assessment for a client who has been vomiting and experiencing diarrhea for the past 6 hours.

Choice D rationale:

“Obtain the client’s serum potassium level.” This is the correct answer. Prolonged vomiting and diarrhea can lead to significant loss of electrolytes, including potassium. A low potassium level (hypokalemia) can have serious effects, including cardiac arrhythmias. Therefore, obtaining the client’s serum potassium level is the priority assessment.

A. Remind the staff members that this is a breach of confidentiality. B. Discuss the issue with the nurse manager. C. Request that an administrative restriction be placed on the client's record access. D. Prepare a memo for the facility ethics committee.

Correct Answer is A

Explanation

Choice A rationale:

Reminding the staff members that viewing the electronic medical record of a celebrity client without proper authorization is a breach of confidentiality is the immediate action required in this situation. It addresses the ethical and legal concerns related to patient privacy and ensures that the staff members are reminded of their professional responsibilities.

Choice B rationale:

Discussing the issue with the nurse manager is a step that can be taken after addressing the immediate breach of confidentiality. While involving the manager is important for handling the situation more comprehensively, the first priority is to stop the unauthorized access.

Choice C rationale:

Requesting an administrative restriction on the client's record access is an option that can be considered, but it may not be the first step to take. Before implementing such a restriction, the breach of confidentiality should be addressed directly with the staff members involved.

Choice D rationale:

Preparing a memo for the facility ethics committee is not the initial action to take in response to the breach of confidentiality. This step might be appropriate for addressing systemic issues or policy changes related to confidentiality breaches, but it doesn't directly address the immediate situation at hand.

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A nurse is assigning care for four clients. Which of the following tasks should the nurse plan to delegate to an assistive personnel (AP)?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who reports vomiting and diarrhea for the past 6 hours. The nurse should identify that which of the following assessments is the priority?

Correct Answer is D

Explanation

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Correct Answer is A

Explanation

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