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
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Correct Answer is B
Explanation
A. Granulex is a topical medication used for wound care, but it may not be the first choice for a stage II pressure ulcer.
B. Hydrocolloid dressings are appropriate for stage II pressure ulcers, providing a moist environment to support healing and protecting the wound from contamination.
C. Proteolytic enzymes are used for debridement of necrotic tissue and may not be the primary choice for a stage II pressure ulcer.
D. Cortisone cream is a topical steroid that may be used for certain skin conditions but is not typically the first-line treatment for pressure ulcers.
Correct Answer is C
Explanation
A. Raising the index finger is not a typical response for managing gagging during NG tube insertion.
B. Bearing down during insertion is not an appropriate instruction and may increase the risk of complications.
C. Instructing the client to say "stop" if a burning sensation is felt inside the nose allows for communication and prompt action to ensure the client's comfort and safety.
D. Inhaling forcefully during insertion is not a recommended action and may interfere with the procedure.
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