A nurse is delegating tasks for an assistive personnel (AP) to perform for a client who is 1-day postoperative following cardiac surgery. Which of the following tasks should the nurse perform herself?

Helping the client into the shower

Ambulating the client in the hallway

Measuring vital signs

Removing the sternal dressing

Answer and Explanation

The Correct Answer is D

A. Helping the client into the shower: This task can be safely delegated to an assistive personnel (AP). The AP can help the client with activities of daily living such as showering, as long as the client is stable and does not require close monitoring.

B. Ambulating the client in the hallway: This task can also be delegated to an AP. Assisting with ambulation is within the scope of practice for an AP, provided the client is stable and there are no specific concerns that require a nurse’s assessment.

C. Measuring vital signs: While measuring vital signs is a critical task, it can be delegated to an AP. The AP can be trained to accurately measure and report vital signs. However, the nurse should review and interpret the results.

D. Removing the sternal dressing: This is the correct answer. Removing a sternal dressing after cardiac surgery is a complex task that requires a nurse’s expertise2. The nurse needs to assess the surgical site for signs of infection or complications, which is beyond the scope of practice for an AP. Therefore, this task should not be delegated and should be performed by the nurse herself

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Correct Answer is D

Explanation

(A) Increased bowel sounds
At the end of life, decreased bowel sounds or even absent bowel sounds are more common due to reduced gastrointestinal activity as the body begins to shut down. Increased bowel sounds are not typically expected.

(B) Hypertension
Hypertension is not typically expected at the end of life. Instead, hypotension (low blood pressure) is more common as the heart and other systems begin to fail.

(C) Moist mucous membranes
At the end of life, mucous membranes are often dry due to decreased fluid intake and systemic dehydration. Moist mucous membranes would not be an expected finding.

(D) Mottled skin
Mottled skin is a common and expected finding at the end of life. It occurs as circulation diminishes and the skin takes on a blotchy, purplish appearance, typically starting in the extremities and moving centrally. This is a sign that the body is shutting down and approaching death.

A. Root cause analysis B. Evidence based practice C. Benchmarking D. Standardization

Correct Answer is B

Explanation

A. Root cause analysis:

Root cause analysis is a method used to identify the underlying causes of adverse events or errors. While it is important for quality improvement and risk management, it does not specifically involve using research and scientific data to guide clinical decision-making in client care.

B. Evidence-based practice:

Evidence-based practice (EBP) involves integrating the best available evidence from research studies with clinical expertise and patient preferences to guide decision-making in client care. By utilizing research and scientific data, nurses can identify effective interventions and strategies to improve client outcomes.

C. Benchmarking:

Benchmarking involves comparing performance metrics or outcomes against standards or best practices. While benchmarking can inform quality improvement efforts, it does not directly involve using research and scientific data to guide clinical decision-making.

D. Standardization:

Standardization involves implementing consistent processes or protocols to improve quality and safety. While standardization is important for ensuring consistency in care delivery, it does not necessarily rely on research and scientific data to inform clinical decision-making as evidence-based practice does.

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A nurse is delegating tasks for an assistive personnel (AP) to perform for a client who is 1-day postoperative following cardiac surgery. Which of the following tasks should the nurse perform herself?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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