A nurse is delegating client care assignments for the upcoming shift. Which of the following tasks should the nurse plan to delegate to the assistive personnel (AP)?
Collecting intake and output.
Evaluating pain relief after administering pain medication.
Providing a central line dressing change.
Selecting a menu for a low-sodium diet.
The Correct Answer is A
Assistive personnel (AP), also known as unlicensed assistive personnel (UAP), can perform tasks such as recording vital signs ¹. Collecting intake and output [a] is a task that can be delegated to an AP.
The other options are not tasks that should be delegated to an AP.
Evaluating pain relief after administering pain medication [b] involves assessing the effectiveness of a medical intervention, which is typically the responsibility of a licensed nurse.
Providing a central line dressing change [c] is a complex task that requires specialized knowledge and skills.
Selecting a menu for a low-sodium diet [d] involves dietary planning, which is typically the responsibility of a licensed nurse or a registered dietitian.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The correct answer is Choice C.
Choice A rationale: A client who had a blood transfusion and has a blood pressure of 138/76 mm Hg. This client is stable. The blood pressure is within normal range, indicating that the client is not experiencing a transfusion reaction, which could cause hypotension. Therefore, this client is not the highest priority.
Choice B rationale: A client who has skeletal traction for a femur fracture and reports incisional discomfort of 4 on a scale of 0 to 10. While pain management is an important aspect of client care, a pain level of 4 indicates that the client’s pain is manageable. Therefore, this client is not the highest priority.
Choice C rationale: A client who is 4 hours postoperative following a total hip arthroplasty and has a urinary output of 15 mL/hr. This client is showing signs of oliguria, which could indicate a serious complication such as hypovolemia or acute kidney injury. This client is the highest priority because these complications can lead to further serious issues such as shock or end-organ damage if not addressed promptly.
Correct Answer is B
Explanation
A nurse's best protection against negligence or malpractice is to follow the standards of practice. These standards define the acceptable level of care that a nurse is expected to provide and are based on current evidence and professional consensus. By adhering to these standards, a nurse can demonstrate that they have provided care that meets the expected level of quality and safety.
The other options are not the best protection against negligence or malpractice. Asking permission from the managing nurse prior to performing any duties [a] may be helpful in some situations, but it is not a guarantee against negligence or malpractice. Never being alone with a patient [c] is not practical or necessary for providing safe and effective care. Recording patient interactions with your phone [d] may violate patient privacy and is not an effective way to prevent negligence or malpractice.
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