A nurse is giving a report to their supervisor. Which of the following indicates a need for client care to be transferred to a registered nurse?
The client needs strict measurement of intake and output.
The client develops a postoperative fever.
The client is experiencing a therapeutic effect from their treatment
The client needs routine wound care performed.
The Correct Answer is B
Rationale:
A. The client needs strict measurement of intake and output: This task can be delegated to assistive personnel as it involves routine data collection without complex clinical judgment.
B. The client develops a postoperative fever: A postoperative fever may indicate infection or other complications requiring assessment, clinical judgment, and intervention by a registered nurse.
C. The client is experiencing a therapeutic effect from their treatment: Monitoring expected therapeutic effects is routine and can often be overseen by licensed practical nurses or assistive personnel, depending on policy.
D. The client needs routine wound care performed: Routine wound care is generally a delegated nursing task that does not require the advanced assessment or clinical decision-making of an RN unless complications arise.
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Related Questions
Correct Answer is A
Explanation
Rationale:
A. Nurse addressing the client directly while the interpreter is present: This demonstrates culturally competent and client-centered care. Documenting that the nurse communicated directly with the client through a qualified interpreter shows appropriate use of interpretation services and respect for the client's autonomy.
B. Nurse asking the client for questions at the end of the instructions: While this is good practice, it does not specifically demonstrate that the client's language needs were addressed. Without interpreter documentation there’s no assurance the client understood the information.
C. Staff member serving as an interpreter for the client: Unless the staff member is a certified medical interpreter, using them for interpretation may result in miscommunication and is not best practice. Documentation should reflect use of trained professionals.
D. Family member acting as an interpreter for the client: Family members should not be used for interpretation due to risks of bias, inaccuracies, and privacy violations. Professional interpreters are necessary to ensure accurate, safe, and confidential communication.
Correct Answer is A
Explanation
Rationale:
A. Request the AP to provide a return demonstration of the task: Having the assistive personnel perform a return demonstration allows the nurse to directly observe their technique, ensuring the AP is competent and following proper procedures to prevent complications such as aspiration or infection.
B. Tell the AP to list the steps of the task: While verbalizing steps shows knowledge, it does not guarantee the AP can safely and effectively perform the feeding. Practical demonstration is necessary for skill verification.
C. Ask the family if the AP performed the task correctly: Family feedback may be subjective and is not a reliable method to assess the AP’s competency. The nurse should perform direct assessment.
D. Instruct the AP to report back once the task is complete: Reporting completion alone does not provide information about the quality or safety of the procedure. Direct observation is required to ensure proper technique.
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