A nurse is caring for residents at a long-term care facility following a tornado. Which of the following tasks should the nurse delegate to an assistive personnel?

Determine which clients need priority medical treatment.

Answer questions from area residents who have health concerns.

Perform CPR for a client who is not breathing.

Complete distal capillary refill checks for a client who has an open leg wound.

Answer and Explanation

The Correct Answer is C

A) Determine which clients need priority medical treatment: This task requires clinical judgment and assessment skills beyond the scope of practice for assistive personnel. Nurses are responsible for assessing clients' needs during emergencies and determining priority for medical treatment based on the severity of their conditions.

B) Answer questions from area residents who have health concerns: While it's important to provide information and support to those affected by the tornado, answering questions about health concerns requires knowledge and expertise in healthcare that is typically within the nurse's scope of practice. Nurses should address inquiries and provide education to ensure the well-being of the community.

C) Perform CPR for a client who is not breathing: This task can be delegated to assistive personnel if they are trained and competent in CPR. In emergencies such as cardiac arrest, prompt initiation of CPR can be life-saving. However, it's crucial to ensure that the assistive personnel are properly trained and certified in CPR before delegating this task.

D) Complete distal capillary refill checks for a client who has an open leg wound: While assessing capillary refill is an important aspect of wound care, performing this task for a client with an open leg wound requires specialized knowledge and skills in wound assessment and management. It falls within the scope of nursing practice and should not be delegated to assistive personnel.

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Correct Answer is D

Explanation

A) Triclosan:

Triclosan is an antimicrobial agent commonly found in soaps, hand sanitizers, and other personal care products. While it has broad-spectrum antimicrobial properties, it is not specifically recommended for hand hygiene in the context of C. difficile infection. Alcohol-based antiseptic rubs are preferred due to their rapid and effective action against C. difficile spores.

B) Chlorhexidine gluconate:

Chlorhexidine gluconate is an antimicrobial agent commonly used as a surgical scrub and skin cleanser. While it is effective against a wide range of microorganisms, including bacteria and fungi, its efficacy against C. difficile spores is limited compared to alcohol-based antiseptic rubs. Therefore, it is not the preferred choice for hand hygiene in the context of C. difficile infection.

C) Alcohol-based antiseptic rub:

Hand hygiene is crucial in preventing the transmission of Clostridium difficile, a bacterium that can cause severe gastrointestinal infection. Alcohol-based antiseptic rubs are not highly effective against C. difficile spores. Thorough handwashing with soap and water has demonstrated superior antimicrobial activity compared to alcohol-based rubs and are preferred for hand hygiene in such situations.

D) Non-antimicrobial soap:

Clostridium difficile (C. difficile) is a bacterium that can cause severe gastrointestinal infection, and proper hand hygiene is essential in preventing its transmission. While alcohol-based antiseptic rubs are effective against many pathogens, including C. difficile, non-antimicrobial soap and water are preferred for hand hygiene after caring for a client with C. difficile. Non-antimicrobial soap helps to mechanically remove C. difficile spores from the hands, reducing the risk of transmission. Although alcohol-based rubs are convenient and effective in many situations, they may not be as effective as soap and water for removing spores and should be used in conjunction with thorough handwashing when caring for clients with C. difficile.

A. Undergoing cardiac catheterization B. Receiving moderate sedation C. Suctioning a tracheostomy tube D. inserting a peripheral IV catheter E. inserting an indwelling urinary catheter

Correct Answer is ["A","B"]

Explanation

A) Undergoing cardiac catheterization:

Cardiac catheterization is an invasive procedure that involves threading a thin tube (catheter) through blood vessels to the heart. It carries potential risks, including bleeding, infection, and damage to blood vessels or the heart. Therefore, obtaining informed consent is essential to ensure that the client understands the procedure, its risks, benefits, and alternatives before undergoing it.

B) Receiving moderate sedation:

Moderate sedation (conscious sedation) is a drug-induced state of depressed consciousness during which the client remains responsive to verbal commands. While it is less invasive than general anesthesia, it still carries risks, including respiratory depression, hypotension, and allergic reactions. Informed consent is required to ensure that the client understands the potential side effects and complications associated with sedation.

C) Suctioning a tracheostomy tube:

Suctioning a tracheostomy tube is a routine nursing intervention to remove secretions and maintain airway patency. It does not typically require informed consent unless there are specific circumstances or the client's condition warrants additional explanation or consent, such as if the client is at risk for complications or discomfort during the procedure.

D) Inserting a peripheral IV catheter:

Inserting a peripheral IV catheter is a common nursing procedure that typically does not require informed consent unless there are unusual circumstances or the client's condition warrants additional explanation or consent, such as if the client has specific concerns or medical conditions that may affect the procedure.

E) Inserting an indwelling urinary catheter:

Inserting an indwelling urinary catheter is a routine nursing procedure commonly performed to drain urine from the bladder. Informed consent may be required in certain situations, such as if the client lacks decision-making capacity or if the procedure involves specific risks or considerations that require explanation to the client or their legal representative. However, in most cases, informed consent is obtained as part of the general consent for treatment upon admission to the healthcare facility.

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A nurse is caring for residents at a long-term care facility following a tornado. Which of the following tasks should the nurse delegate to an assistive personnel?

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Naxlex Comprehensive Predictor Exams

A nurse is performing hand hygiene after caring for a client who has Clostridium difficile. Which of the following cleansing agents should the nurse use?

Correct Answer is D

Explanation

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Correct Answer is ["A","B"]

Explanation

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