A nurse is delegating care to assistive personnel. Which of the following assignments should the nurse make?
Reinforcing teaching with a client about stool specimen collection
Collecting a urine specimen from a client who is experiencing dysuria
Taking the vital signs of a client who is experiencing acute angina
Answering a telephone inquiry about NPO status from a client who is scheduled for a procedure
The Correct Answer is B
A) Reinforcing teaching with a client about stool specimen collection:
This task involves providing education to the client, which requires nursing knowledge and judgment. It is not appropriate to delegate to assistive personnel, as they may not have the necessary training or expertise to provide accurate and comprehensive teaching.
B) Collecting a urine specimen from a client who is experiencing dysuria:
Collecting a urine specimen from a client who is experiencing dysuria is an appropriate task to delegate to assistive personnel. This task involves following a standard procedure for specimen collection and does not require specialized nursing judgment or assessment skills.
C) Taking the vital signs of a client who is experiencing acute angina:
Assessing vital signs, especially in a client experiencing acute angina, requires nursing judgment and the ability to recognize and respond to changes in the client's condition. This task should not be delegated to assistive personnel, as they may not have the training to recognize signs of deterioration or respond appropriately.
D) Answering a telephone inquiry about NPO status from a client who is scheduled for a procedure:
Providing information over the phone regarding NPO (nothing by mouth) status involves assessing the client's specific situation, understanding the procedure's requirements, and potentially making clinical decisions based on the client's condition. This task requires nursing judgment and should not be delegated to assistive personnel.
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Related Questions
Correct Answer is A
Explanation
A) The client rates her pain at a 3 on a 0 to 10 pain rating scale:
In the SBAR communication technique, "A" stands for "Assessment." This portion of the report should include concise and pertinent information about the client's current condition or status. The client's pain level, rated on a standardized pain scale, is a crucial assessment parameter that provides immediate insight into the client's comfort and potential need for intervention or further assessment.
B) The client has type 2 diabetes mellitus:
While the client's medical history of type 2 diabetes mellitus is important information, it is more relevant to the client's overall health status and background. In the SBAR framework, this information would typically be included in the "B" (Background) portion of the report, which focuses on contextual information such as medical history, current diagnoses, and relevant background information about the client.
C) The client is 2 hours postoperative following a cholecystectomy:
The fact that the client is 2 hours postoperative following a cholecystectomy is significant information regarding the client's recent surgical procedure and immediate postoperative status. However, this information falls under the "B" (Background) portion of the SBAR report, which includes details about the client's recent events, procedures, or treatments.
D) The client should wear compression stockings:
Information about the client's prescribed interventions or treatments, such as wearing compression stockings, is essential for continuity of care and ensuring that appropriate interventions are continued. However, this information is typically included in the "R" (Recommendation) portion of the SBAR report, where the nurse may provide recommendations for ongoing care or interventions based on the client's current condition and needs.
Correct Answer is C
Explanation
A) Restraining a client without a provider's prescription:
This action represents assault and false imprisonment rather than negligence. Assault involves the threat of harm or unwanted touching, while false imprisonment involves the unlawful restraint or restriction of a person's freedom of movement.
B) Threatening to administer a medication a client has refused:
Threatening to administer a medication against a client's wishes may constitute assault or battery, depending on the circumstances, but it does not directly relate to negligence unless the threat results in harm due to the nurse's failure to adhere to the standard of care.
C) Failing to notify the provider after a medication error:
Negligence involves a breach of duty of care resulting in harm to another person. Failing to notify the provider after a medication error represents negligence because it breaches the duty of care owed to the client and may result in harm if appropriate actions are not taken promptly to mitigate the error's effects.
D) Documenting false information in a client's medical record:
Documenting false information in a client's medical record is a form of falsifying documentation and can have serious consequences, including legal and professional repercussions. However, it does not directly relate to negligence unless the false documentation leads to harm or adverse outcomes for the client.
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