A nurse is caring for a client who repeatedly refuses meals.
The nurse overhears an assistive personnel (AP) telling the client, “If you don’t eat, I’ll put restraints on your wrists and feed you.” The nurse should intervene and explain to the AP that this statement constitutes which of the following torts?

B. Review the skill level and qualifications of each AP.

Before delegating tasks, the nurse should assess the skill level and qualifications of each AP to ensure they have the necessary knowledge and training to perform the assigned tasks safely and effectively.

D. Communicate appropriate tasks to the APs with specific expectations.

The nurse should clearly communicate the tasks to be delegated to each AP. This includes providing specific instructions, expectations, and any necessary information to ensure the APs understand what is expected of them and can perform the tasks correctly.

A. Monitor progress of task completion with each AP.

Once the tasks are assigned, the nurse should periodically check in with each AP to monitor the progress of task completion. This allows the nurse to provide support, answer questions, and ensure that tasks are being performed as expected.

C. Evaluate the APs' performance of each task.

After the tasks are completed, the nurse should evaluate the APs' performance of each task. This evaluation helps identify any areas for improvement, additional training needs, and overall competency of the APs.

Delegating tasks to assistive personnel is an essential aspect of nursing practice. Following this sequence of steps helps ensure that tasks are delegated appropriately and that the care provided is safe, efficient, and aligned with the APs' capabilities. Regular communication and feedback are essential to effective task delegation and teamwork within the healthcare setting.

The correct answer is choice D: A client who is taking warfarin and has an INR of 1.8.

Choice A rationale:

A Mantoux test with an induration after 48 hours can be a normal reaction, especially if the induration is within the expected size range for a positive result, depending on the individual’s risk factors and history. It does not necessarily require follow-up care unless the induration is significantly large or there are other concerning symptoms.

Choice B rationale:

A client scheduled for a colonoscopy and taking sodium phosphate does not typically require follow-up care for the sodium phosphate intake itself. Sodium phosphate is commonly used as a bowel prep medication to clear the intestines prior to the procedure.

Choice C rationale:

A potassium level of 3.6 mEq/L is within the normal range (3.5-5.0 mEq/L), so a client taking bumetanide with this potassium level would not typically require follow-up care for the potassium level alone.

Choice D rationale:

A client taking warfarin with an INR of 1.8 requires follow-up care because the therapeutic range for warfarin is typically between 2.0 and 3.0 for most indications. An INR of 1.8 may indicate that the blood is not “thin” enough, increasing the risk of thrombotic events, and the warfarin dose may need adjustment.