A nurse is delegating tasks to a group of staff members. Which of the following tasks should the nurse assign to an assistive personnel?
Irrigate a client's incision.
Determine a client's pain level.
Insert a nasogastric tube.
Provide postmortem care.
The Correct Answer is D
A. Irrigate a client's incision: Wound irrigation is a sterile procedure that requires nursing judgment and skill to prevent infection and assess wound healing. This task should not be delegated to assistive personnel.
B. Determine a client's pain level: Assessing pain requires clinical judgment to interpret subjective and objective findings and evaluate the need for interventions. This responsibility remains with the licensed nurse.
C. Insert a nasogastric tube: Insertion of a nasogastric tube is an invasive procedure that requires nursing knowledge and technical skill to ensure proper placement and prevent complications. It is not within the scope of assistive personnel.
D. Provide postmortem care: Postmortem care is a noninvasive task that involves preparing the body, performing hygiene, and maintaining dignity. It falls within the scope of practice for assistive personnel and can be safely delegated.
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Related Questions
Correct Answer is B
Explanation
Rationale:
A. Discuss the client's preferences for determining a repositioning schedule: While involving the client in care planning is important, the schedule for repositioning is primarily determined by clinical needs to prevent complications such as pressure injuries, not solely by preference.
B. Evaluate the client's ability to help with repositioning: Assessing the client’s strength, mobility, and coordination after a stroke determines the level of assistance and equipment required. This ensures safety for both the client and the nurse during repositioning.
C. Raise the side rails of the client’s bed during repositioning: Side rails can create entrapment hazards if used incorrectly and should not be relied upon during repositioning. Their purpose is more for safety positioning after the move, not as a primary tool during the maneuver.
D. Reposition the client with the assistive devices: Assistive devices should be used if needed, but this step follows an assessment of the client’s capabilities. Selecting equipment without first evaluating the client may lead to unnecessary interventions.
Correct Answer is C
Explanation
A. "You will be given access to the medical records of every client in the facility.": Access to electronic medical records is restricted based on the nurse’s role and need-to-know basis to protect client confidentiality. Nurses only view records of clients under their care.
B. "You will be asked to change your password once per year.": Most facilities require more frequent password changes, often every 60–90 days, to maintain system security. Annual changes alone are insufficient for protecting client data.
C. "Information Technology will install a firewall to secure client information.": Firewalls and other cybersecurity measures help protect electronic health information from unauthorized access. Including this ensures nurses understand that the system has built-in technical safeguards for privacy and security.
D. "Documentation of sensitive material is performed by the charge nurse.": All licensed nurses are responsible for accurate, complete, and timely documentation of client care, including sensitive material. Responsibility is not limited to the charge nurse.
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