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 ["A","B","C","D"]

Explanation

A) Assist in checking a unit of packed RBCS to administer to a client:

Assisting in checking a unit of packed red blood cells (RBCs) for transfusion is within the nurse's scope of practice. Nurses are responsible for verifying blood products before administration, ensuring compatibility, proper labeling, and appropriate handling to prevent transfusion reactions.

B) Regulate the client's infusion pump after initiating a heparin drip infusion:

Regulating the client's infusion pump after initiating a heparin drip infusion falls within the nurse's scope of practice. Nurses commonly administer and monitor intravenous medications, including heparin drips, and are responsible for regulating the infusion pump to deliver the medication at the prescribed rate.

C) Teach a client about hemodialysis:

Teaching a client about hemodialysis is within the nurse's scope of practice. Patient education is a fundamental aspect of nursing care, and nurses often provide information to clients and their families about various healthcare procedures, treatments, and self-care management, including hemodialysis.

D) Create a plan of care for a client's discharge:

Creating a plan of care for a client's discharge is within the nurse's scope of practice. Nurses are involved in discharge planning, which includes coordinating with the healthcare team, assessing the client's needs, providing education about post-discharge care, arranging follow-up appointments, and ensuring a smooth transition to the next level of care or home.

A. Establishing the priorities of client care B. Reinforcing teaching about the client's diagnosis C. Asking the client about the presence of pain D. Comparing the client's current laboratory values to previous results

Correct Answer is B

Explanation

A) Establishing the priorities of client care:

Establishing priorities of client care typically occurs during the planning phase of the nursing process, not during implementation. During the planning phase, the nurse identifies the most urgent client needs based on assessments and formulates a plan of action to address those needs.

B) Reinforcing teaching about the client's diagnosis:

Reinforcing teaching about the client's diagnosis is an appropriate activity during the implementation phase of the nursing process. Implementation involves carrying out the planned interventions, which may include educating the client about their diagnosis, treatment plan, and self-care strategies. Reinforcing teaching ensures that the client understands their condition and how to manage it effectively.

C) Asking the client about the presence of pain:

Assessing the client for pain is typically part of the assessment phase of the nursing process, not the implementation phase. During assessment, the nurse gathers data about the client's pain experience, including location, intensity, quality, and factors that alleviate or exacerbate pain.

D) Comparing the client's current laboratory values to previous results:

Comparing laboratory values is a component of data interpretation and analysis, which occurs primarily during the evaluation phase of the nursing process. While the nurse may review laboratory values during implementation to monitor the client's response to interventions, comparing current values to previous results is more closely associated with evaluating the effectiveness of care provided.

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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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