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 B

Explanation

A) Ask ambulatory clients to help to move clients in wheelchairs:

While enlisting the help of ambulatory clients to assist those in wheelchairs may seem logical, it is not typically recommended as it could pose safety risks to both parties during an evacuation. Assistive personnel should be trained to prioritize their own safety and the safety of others during evacuation procedures, following established protocols for assisting clients with mobility impairments.

B) Place dry towels around the bases of doors:

Placing dry towels around the bases of doors is a recommended fire evacuation procedure to prevent smoke from entering the room. This action helps create a barrier to smoke inhalation and can buy time for evacuation or rescue efforts. It is important to use dry towels or clothing to avoid fueling the fire and to minimize the passage of smoke.

C) Carry bedridden clients to safety by lifting them onto your back:

Carrying bedridden clients on one's back during a fire evacuation is not a safe or feasible method, especially for assistive personnel who may not have the physical strength or training to perform such tasks. Evacuating bedridden clients should be done using appropriate evacuation equipment such as evacuation sleds or sheets, following facility protocols and guidelines.

D) Aim the extinguisher at the top of the fire:

While using a fire extinguisher is an important aspect of fire safety training, aiming the extinguisher at the top of the fire is not always the correct approach. The appropriate technique for using a fire extinguisher depends on the type of fire and the specific instructions provided with the extinguisher. It is essential for assistive personnel to receive proper training on fire extinguisher use and to follow established procedures during emergencies.

A. "Have you tried holding your infant skin-to-skin?" B. "is your infant able to latch on during breastfeeding?" C. "What is your infant's level of activity?" D. "Have you considered joining a parents' support group?"

Correct Answer is B

Explanation

A) "Have you tried holding your infant skin-to-skin?":

While skin-to-skin contact can be beneficial for infant bonding and comfort, the priority for a postoperative infant following a cleft palate repair is to ensure adequate feeding. While skin-to-skin contact can promote bonding and provide comfort, it does not directly address the infant's ability to latch on during breastfeeding, which is crucial for nutritional intake and healing postoperatively.

B) "Is your infant able to latch on during breastfeeding?":

This question addresses the priority concern for the nurse, which is the infant's ability to effectively latch on during breastfeeding. Adequate latch is essential for proper nutrition and hydration, especially for an infant recovering from a cleft palate repair surgery. The nurse needs to assess whether the infant can latch on properly to ensure adequate feeding and support optimal healing.

C) "What is your infant's level of activity?":

While assessing the infant's level of activity is important for overall health and well-being, it is not the priority question in this scenario. The nurse's primary focus should be on assessing the infant's feeding ability and ensuring adequate nutritional intake postoperatively.

D) "Have you considered joining a parents' support group?":

Joining a parents' support group can be valuable for emotional support and sharing experiences, but it is not the priority question in this situation. The immediate concern is ensuring the infant's nutritional needs are being met, particularly in the context of breastfeeding challenges following cleft palate repair surgery.

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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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