A nurse is delegating client care tasks to assistive personnel. Which of the following tasks should the nurse delegate?
Evaluating the healing of an incision
Changing IV tubing
Performing a simple dressing change
Inserting an NG tube
The Correct Answer is B
Choice A reason:
Evaluating the healing of an incision is not necessary because it involves clinical judgment and assessment skills, which are generally beyond the scope of practice for assistive personnel.
Choice B reason:
Changing IV tubing is a task that can often be safely delegated to an assistive personnel (AP) who has been trained and deemed competent to perform this task. It is within the AP's scope of practice and doesn't require clinical judgment or assessment.
Choice C reason:
Performing a simple dressing change involves direct contact with a wound and requires knowledge of aseptic technique and wound care principles. This task is typically performed by licensed nursing personnel.
Choice D reason:
Inserting an NG tube is a complex procedure that requires specialized training and skill. It should be performed by a licensed nurse or another healthcare professional with the appropriate training and competence.
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Related Questions
Correct Answer is C
Explanation
Choice A reason:
Documenting the fluid infusion in the client's chart: While documenting the fluid infusion is important, assessing the client's vital signs should take priority to ensure their immediate safety and well-being.
Choice B reason:
Completing an incident report is incorrect Completing an incident report is a necessary step to document the error and initiate appropriate follow-up actions, but it should come after assessing the client's condition.
Choice C reason
Obtaining the client's vital signs is the correct answer. The correct first action for the nurse to take in this situation is to obtain the client's vital signs. Administering an excessive amount of IV fluid could potentially have adverse effects on the client's cardiovascular system, including fluid overload, electrolyte imbalances, and changes in blood pressure. Monitoring the client's vital signs will help assess their current condition and any potential complications resulting from the excess fluid administration.
Choice D reason
Reporting the incident to the unit manager is incorrect. Reporting the incident to the unit manager is important for organizational awareness and accountability, but the nurse's first responsibility is to assess the client's vital signs and address any potential complications.
Correct Answer is ["A","D","E"]
Explanation
A. Place the client in a room with positive air flow: Placing the client in a room with positive air flow helps prevent the spread of infectious agents within the healthcare facility. This is particularly important for clients with airborne infections.
D. Provide a mask for the client when they are outside their room: Providing a mask for the client when they are outside their room helps prevent the spread of infectious agents to others if the client has a contagious respiratory infection.
E. Don a gown when entering the client's room: Wearing a gown upon entering the client's room helps protect the nurse from contact with the client's body fluids and reduces the risk of transmitting pathogens to other clients or healthcare workers.
B. Perform hand hygiene with at least 4 to 5 mL of hand sanitizer when leaving the client's room: Hand sanitizer is not a substitute for proper handwashing with soap and water. Hand sanitizer may be used in addition to handwashing, but it is not used with such a specific quantity.
C. When removing personal protective equipment, remove gloves first: When removing personal protective equipment, the correct sequence is to remove gloves, perform hand hygiene, and then remove other items such as gown, mask, and eyewear. This helps prevent contamination of the hands during the process.
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