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 A

Explanation

Choice A rationale:

Providing the client with information about advance directives is an appropriate intervention. Advance directives are legal documents that allow individuals to communicate their preferences for medical treatment in the event they become unable to make decisions for themselves. Educating the client about the importance and benefits of advance directives empowers them to make informed decisions about their care.

Choice B rationale:

Encouraging the client to contact an attorney to create advance directives is not the primary responsibility of the hospice nurse. While legal assistance might be helpful, the nurse should first ensure that the client understands the concept of advance directives and their significance before suggesting legal involvement.

Choice C rationale:

Informing the client that they will need a relative to witness their advance directives is not accurate. While witnesses are often required when signing legal documents, the specific requirements for advance directives can vary by jurisdiction. It's important for the nurse to provide accurate information and not make assumptions about legal processes.

Choice D rationale:

Telling the client that The Joint Commission requires clients to have advance directives is not accurate. While The Joint Commission emphasizes the importance of patient rights and informed decision-making, it does not mandate that all clients must have advance directives. The decision to create advance directives is a personal choice and should be based on the individual's values and preferences.

A. The nurse places the sterile package with the top flap opening away from the body. B. The nurse pinches the flap on the inside of the package first to open it. C. The nurse reaches over the package to open the left flap. D. The nurse pulls the last flap of the package away from the body.

Correct Answer is A

Explanation

Choice A rationale:

Placing the sterile package with the top flap opening away from the body is the correct choice. This technique helps maintain the sterility of the contents by preventing potential contamination from the nurse's body and clothing.

Choice B rationale:

Pinching the flap on the inside of the package first to open it is not a recommended sterile technique. It could potentially introduce contamination from the nurse's hand into the sterile field when pinching the inner flap.

Choice C rationale:

Reaching over the package to open the left flap is not the ideal technique. Reaching over the sterile field can introduce the risk of contamination, as the nurse's arm and body might come into contact with the sterile supplies.

Choice D rationale:

Pulling the last flap of the package away from the body is not the most effective technique. This action could potentially lead to the nurse's hand coming close to or over the sterile field, increasing the risk of contamination.

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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)?

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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)?