A nurse is assisting with planning care for a group of clients. Which of the following tasks should the nurse delegate to an assistive personnel?
Changing the dressing on a client's IV site
Suctioning a client's new tracheostomy
Evaluating a client's risk for developing pressure injuries
Administering a large-volume enema to a client
The Correct Answer is D
A. Changing the dressing on a client's IV site: This is a sterile procedure and requires the nurse’s clinical expertise. It cannot be delegated to assistive personnel (AP).
B. Suctioning a client's new tracheostomy: Suctioning a tracheostomy, especially a new one, is a sterile procedure requiring clinical judgment and skill, which is beyond the scope of assistive personnel.
C. Evaluating a client's risk for developing pressure injuries: This is an assessment task that requires clinical judgment and critical thinking. It falls under the nurse’s scope of practice and should not be delegated to AP.
D. Administering a large-volume enema to a client: Assisting with or administering an enema is a task that can be delegated to assistive personnel, as it is within their scope of practice, provided the client is stable and the procedure does not require complex judgment.
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Related Questions
Correct Answer is C
Explanation
A. Pitting edema: Pitting edema is a sign of fluid retention and is not specifically associated with hypokalemia.
B. Diplopia: Diplopia refers to double vision and is not typically associated with hypokalemia.
C. Muscle weakness: Hypokalemia can lead to muscle weakness due to the impaired function of skeletal muscles.
D. Hyperactive bowel sounds: Hyperactive bowel sounds can occur in conditions such as diarrhea but are not specific to hypokalemia.
Correct Answer is D
Explanation
A. Preschoolers have short attention spans, so a 30-minute instructional session may not be effective and may overwhelm the child.
B. Scheduling the instructional session for 24 to 36 hours before the procedure may not be appropriate for a preschooler, as they may not retain the information for that length of time.
C. Taking the child on a tour of the surgery and recovery areas may be overwhelming and frightening for a preschooler, potentially increasing anxiety about the procedure.
D. Helping the child put a dressing on a doll is a developmentally appropriate technique for preparing a preschooler for a procedure. It allows the child to engage in hands-on learning and role-playing, helping them understand what will happen during the procedure and providing an opportunity to express any fears or concerns.
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