A nurse is delegating care for a group of four clients. Which of the following tasks should the nurse delegate to an assistive personnel (AP)?
Irrigate and perform a dressing change for a client who has a pressure injury wound.
Administer oral PRN pain medication to a client who has arthritis.
Obtain a daily weight on a client who has heart failure.
Reinforce teaching the use of an incentive spirometer to a postoperative client.
The Correct Answer is C
Choice A reason: Irrigating and performing a dressing change for a client who has a pressure injury wound is not a task that the nurse should delegate to an AP. This task requires the nurse's clinical judgment, skill, and knowledge to assess the wound, select the appropriate dressing, and prevent infection. This task is also within the nurse's scope of practice, but not the AP's scope of practice.
Choice B reason: Administering oral PRN pain medication to a client who has arthritis is not a task that the nurse should delegate to an AP. This task involves the nurse's responsibility to evaluate the client's pain level, determine the need and the dosage of the medication, and monitor the client's response and side effects. This task is also within the nurse's scope of practice, but not the AP's scope of practice.
Choice C reason: Obtaining a daily weight on a client who has heart failure is a task that the nurse can delegate to an AP. This task is a routine and standardized procedure that does not require the nurse's clinical judgment, skill, or knowledge. This task is also within the AP's scope of practice, if the nurse provides clear directions and supervision.
Choice D reason: Reinforcing teaching the use of an incentive spirometer to a postoperative client is not a task that the nurse should delegate to an AP. This task involves the nurse's role to educate the client about the purpose, benefits, and technique of using the incentive spirometer, and to evaluate the client's understanding and compliance. This task is also within the nurse's scope of practice, but not the AP's scope of practice.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: There are not 4 rights of delegation, but 5 rights of delegation. The 5 rights of delegation are the right task, the right circumstance, the right person, the right direction or communication, and the right supervision or evaluation. The nurse should know and apply these rights when delegating tasks to other members of the health care team.
Choice B reason: The nurse manager is not the only one responsible for delegating nursing tasks during each shift, but the registered nurse (RN) is also responsible for delegating nursing tasks within their scope of practice. The RN should delegate tasks based on the client's needs, the staff's competencies, and the organizational policies. The nurse manager should support and oversee the delegation process, but not assume the sole responsibility for it.
Choice C reason: It is not the duty of the delegate to perform a task without asking questions when it is delegated, but to ask questions or clarify any doubts or concerns before accepting or performing the task. The delegate should communicate effectively with the delegator and ensure that they understand the task, the expected outcome, the time frame, and the resources available. The delegate should also report any problems or issues that arise during or after the task completion.
Choice D reason: I am responsible for ensuring that a delegated task is completed is a correct statement that indicates understanding of delegation. The delegator is accountable for the decision to delegate and the outcome of the task. The delegator should monitor and evaluate the performance and the results of the task, and provide feedback and recognition to the delegate. The delegator should also intervene or take corrective actions if needed.
Correct Answer is B
Explanation
Choice A reason: Client's skin is pale and diaphoretic is not included in the subjective component, but in the objective component. The objective component records the measurable and observable data that the nurse collects from the client, such as vital signs, physical examination findings, and laboratory results.
Choice B reason: Client reports chest pain after mowing lawn this morning is included in the subjective component. The subjective component records the data that the client verbalizes or expresses, such as symptoms, feelings, preferences, and beliefs.
Choice C reason: Client administered nitroglycerin 0.3 mg SL for chest pain is not included in the subjective component, but in the plan component. The plan component records the interventions and actions that the nurse implements or plans to implement for the client, such as medications, treatments, referrals, and education.
Choice D reason: Client's blood pressure is 182/98 mm Hg is not included in the subjective component, but in the objective component. The objective component records the measurable and observable data that the nurse collects from the client, such as vital signs, physical examination findings, and laboratory results.
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