A nurse is caring for a group of clients and identifying what tasks she can delegate to an assistive personnel (AP). Which of the following tasks should the nurse delegate to an AP?
Administer a glycerin suppository to a client.
Provide home care instructions to a client's family member.
Suction a client's newly inserted tracheostomy.
Perform rescue breathing for a client who becomes unresponsive.
The Correct Answer is D
Choice A rationale
Administering a suppository is considered a medication administration task, which requires a licensed nurse to perform. This task involves critical thinking and a solid understanding of anatomy, physiology, and pharmacology, as well as the potential for adverse reactions. Therefore, this cannot be delegated to an assistive personnel (AP), whose scope of practice does not include medication administration.
Choice B rationale
Providing home care instructions is part of client education, which is a key responsibility of a licensed nurse. This task requires a thorough understanding of the client's condition, treatment plan, and the ability to assess their learning needs. An AP is not trained to assess, plan, or implement teaching plans for clients, so this task is outside their scope of practice.
Choice C rationale
Suctioning a newly inserted tracheostomy is a skilled and invasive procedure that carries a high risk of complications, such as hypoxemia, trauma, or infection. This procedure requires a nurse's professional judgment and a clear understanding of sterile technique. The AP's role is to provide basic care, not to perform such complex and high-risk procedures.
Choice D rationale
Performing rescue breathing, or cardiopulmonary resuscitation (CPR), is an emergency procedure that falls within the scope of an AP's training. All healthcare workers, including APs, are required to have a basic life support certification. In a medical emergency, every staff member is expected to perform basic life-saving measures, such as rescue breathing, to prevent further client harm. *.
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Related Questions
Correct Answer is C
Explanation
Choice A rationale
While larger gauge catheters (e.g., 18-gauge) are used for rapid infusion, they also cause more trauma to the vein's intimal layer during insertion. This trauma can trigger a localized inflammatory response, increasing the risk of phlebitis, which is inflammation of the vein. Smaller gauge catheters (e.g., 22-24 gauge) cause less trauma and are preferred for routine fluid administration to prevent this complication.
Choice B rationale
The non-dominant arm is the preferred site for IV access whenever possible. Using the non-dominant arm allows the client to maintain more normal function and independence with daily activities, as they can still use their dominant hand without the restriction of the IV line. This also minimizes the risk of accidental dislodgement or trauma to the site.
Choice C rationale
Selecting a site proximal to previous venipuncture sites is the recommended practice. When a vein is punctured, it can cause localized inflammation and scar tissue formation distal to the site. Starting proximal allows for the use of a healthier segment of the vein, which improves the likelihood of successful insertion and reduces the risk of extravasation or phlebitis.
Choice D rationale
The palmar side of the client's wrist should be avoided for IV insertion. This area contains a high concentration of nerves and tendons, including the median nerve and radial artery. Inserting a catheter here increases the risk of nerve damage, which can lead to permanent numbness, tingling, or pain, and also increases the risk of arterial puncture. *.
Correct Answer is D
Explanation
Choice A rationale
Activating the fire alarm is a critical step in the RACE sequence (Rescue, Alarm, Contain, Extinguish). However, the immediate priority is to ensure the safety of people. Therefore, alerting others to the fire comes after the initial rescue of individuals in immediate danger. This action is necessary for a coordinated emergency response.
Choice B rationale
Closing doors and windows on the unit is an important step in containing the fire and preventing the spread of smoke and flames. This action follows the evacuation of individuals in immediate danger and is part of the "Contain" step of the RACE protocol. Containment helps to protect other areas of the facility.
Choice C rationale
Obtaining and using a fire extinguisher is a valid action, but only after clients in immediate danger have been evacuated and the fire alarm has been activated. The "Extinguish" step is only to be performed if the fire is small and contained and the person is trained to use the extinguisher, and it does not pose a risk to the person.
Choice D rationale
The primary responsibility of a nurse during a fire is to protect the clients. The acronym RACE guides this response: Rescue, Alarm, Contain, and Extinguish. The first and most critical step is to remove clients from the immediate danger area, which takes precedence over all other actions. *.
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