A nurse is delegating obtaining the collection of a client's oral temperature to an assistive personnel (AP). The nurse notes in the documentation that the AP obtained the client's axillary temperature. Which of the following rights of delegation should have prevented this situation from occurring?

Right task

Right communication

Right person

Right circumstance

Answer and Explanation

The Correct Answer is A

A.   The right task involves ensuring that the delegated task is appropriate for delegation. In this case, obtaining an oral temperature should have been the correct task; however, the AP
performed the axillary temperature, indicating a deviation from the right task.
B.   Right communication involves clear and effective communication between the nurse and the assistive personnel but is not directly related to the task performed.
C.   Right person involves ensuring that the task is delegated to a competent and qualified

individual. The issue in this scenario is with the task itself, not the competency of the individual.

D. Right circumstance involves ensuring that the conditions are appropriate for delegation. While the circumstance is important, the primary concern in this case is the mismatch between the task and the method of temperature measurement.

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Correct Answer is C

Explanation

A. Vest restraints are not appropriate for seizure precautions. Restraints are generally not recommended as the primary intervention for seizure management.
B. The use of tongue blades during a seizure is not recommended and could pose a risk of injury.
C. Oxygen setup is crucial for managing a client during and after a seizure to ensure proper oxygenation.
D. Neck brace is not necessary for seizure precautions and may pose a risk during a seizure episode.

A. "Raise your head off the pillow." B. "Bear down." C. "Hold your breath." D. "Perform Kegel exercises."

Correct Answer is B

Explanation

A. Raising the head off the pillow is not relevant to easing the passage of the catheter through the urinary meatus.
B. Bearing down can help relax the pelvic floor muscles, making it easier to insert the catheter through the urinary meatus.
C. Holding the breath is not typically instructed during catheter insertion and may not aid in the ease of the procedure.
D. Performing Kegel exercises involves contracting pelvic floor muscles, which is not the desired action when inserting a urinary catheter.

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A nurse is delegating obtaining the collection of a client's oral temperature to an assistive personnel (AP). The nurse notes in the documentation that the AP obtained the client's axillary temperature. Which of the following rights of delegation should have prevented this situation from occurring?

Nursing Test Bank

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Correct Answer is C

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Correct Answer is B

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