A nurse is caring for a patient who has an active upper gastrointestinal bleed.
After inserting a nasogastric (NG) tube into the patient, what findings should the nurse anticipate?

Choice A rationale

The nurse should indeed consider the AP’s level of experience when making delegation decisions. This is because the level of experience can greatly influence the ability of the AP to perform the delegated tasks effectively and safely. An experienced AP may be more competent and confident in performing certain tasks compared to someone with less experience. Therefore, considering the AP’s level of experience is crucial in ensuring quality care for patients.

Choice B rationale

While it is true that APs can assist in providing client education about basic self-care, it is important to note that the scope of their teaching is limited. They can reinforce teaching done by the nurse but should not be the primary source of education, especially for complex care needs or new diagnoses. Therefore, this statement does not fully reflect effective delegation.

Choice C rationale

This statement is incorrect. Even when care is delegated to an AP, the nurse retains accountability for client outcomes. The nurse remains responsible for ensuring that the delegated tasks are completed correctly and safely. Therefore, this statement does not indicate effective delegation.

Choice D rationale

This statement is also incorrect. APs should not re-delegate tasks to another AP1. The nurse who delegated the task has assessed the competency and capabilities of the specific AP to whom the task was delegated. Re-delegation could lead to tasks being performed by someone who may not have the necessary skills or knowledge, potentially compromising patient safety.

Choice A rationale

Returning the platelet bag and tubing to the blood bank is not the immediate action to take when a client reports having lower back pain and feeling chilled and itchy during a PRBC transfusion. These symptoms could indicate a transfusion reaction, which is a serious complication that requires immediate intervention.

Choice B rationale

Stopping the infusion is the first action the nurse should take when a client reports symptoms of a transfusion reaction. This is because continuing the transfusion could worsen the reaction and potentially lead to more serious complications.

Choice C rationale

While notifying the provider is an important step in managing a transfusion reaction, it is not the first action the nurse should take. The nurse should first stop the infusion to prevent further exposure to the blood product.

Choice D rationale

Collecting a urine sample from the client is not the immediate action to take when a client reports having lower back pain and feeling chilled and itchy during a PRBC transfusion. These symptoms could indicate a transfusion reaction, which requires immediate intervention.