A nurse is coordinating care of a group of clients with an assistive personnel (AP). Which of the following tasks should the nurse assign to the AP?
A. Assess the pain level of a client who has received acetaminophen.
Check a client's peripheral IV site for redness or swelling.
Measure the intake and output of a client who has received furosemide.
Reinforce teaching with a client about crutch-gait walking.
The Correct Answer is C
Choice A rationale
Assessing pain levels is a nursing task requiring clinical judgment, which is beyond the scope of an assistive personnel's duties.
Choice B rationale
Checking an IV site for redness or swelling also requires clinical assessment skills, which are tasks for the nurse.
Choice C rationale
Measuring intake and output is a routine task that can be safely delegated to an assistive personnel. It involves straightforward measurement and recording.
Choice D rationale
Reinforcing teaching about crutch-gait walking requires specific patient education, which falls under the nurse's responsibilities.
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Related Questions
Correct Answer is D
Explanation
Choice A rationale
Placing one hand over the other against the upper body of the gown increases the risk of contamination. The sterile field must be maintained by keeping hands in a position where they are less likely to come into contact with non-sterile surfaces.
Choice B rationale
Clasping hands behind the body at the waist can also lead to contamination, as the hands may inadvertently touch the gown, which may not be sterile in that area. It’s essential to keep hands in a position where they are less likely to become contaminated.
Choice C rationale
Keeping arms at the sides with hands in a relaxed position might cause hands to brush against non-sterile surfaces or clothing, leading to contamination. Therefore, this position is not recommended for maintaining sterility.
Choice D rationale
Interlocking fingers and holding hands away from the body above the waist is the proper technique for maintaining sterility. This position ensures that the hands are kept in the sterile field and away from non-sterile surfaces, reducing the risk of contamination.
Correct Answer is C
Explanation
Choice A rationale
Telling the client's partner to discuss their feelings when not feeling overwhelmed is dismissive. It does not address their current emotional state or offer support. This response can make the partner feel unheard and may not provide immediate relief or understanding.
Choice B rationale
Suggesting that the partner take the client with them when going out may not be practical, especially considering the advanced stage of Alzheimer's disease. This response can show a lack of understanding of the challenges faced by caregivers of individuals with severe cognitive impairment.
Choice C rationale
Asking the partner to share more about their expectations opens a dialogue and shows empathy. It allows the nurse to understand the partner’s feelings and needs better, providing an opportunity for supportive and individualized advice.
Choice D rationale
While expressing understanding and sharing a personal experience might build rapport, it can shift the focus away from the partner's feelings and needs. The nurse should remain client-centered, providing support specific to the partner's situation rather than comparing it to their own.
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