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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. 2+ pitting edema is not a contraindication to cold application; in fact, cold application can help reduce edema.
B. A 7.5 cm (3 in) diameter bruise on the ankle is not a contraindication to cold application; cold can help reduce swelling and alleviate pain.
C. Capillary refill of 4 seconds suggests compromised blood flow, and cold application may further impair circulation. It is a contraindication.
D. Warts on the affected ankle are not a contraindication to cold application.
Correct Answer is C
Explanation
A. Opening the first flap of the sterile kit away from the body helps maintain the sterility of the contents.
B. The sterile field should be above waist level to avoid contamination.
C. Placing dry, sterile supplies 1/2 inch from the edge of the sterile field helps prevent contamination of the items.
D. Sterile gloves should be donned before preparing the sterile field to avoid contamination.
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