A nurse is making assignments for staff on an inpatient unit. Which of the following tasks can a nurse legally delegate to assistive personnel?
Obtaining the initial assessment of assigned clients
Educating a client and family members on home care
Changing a nonsterile dressing
Interpreting a client's diagnostic laboratory results
The Correct Answer is C
Rationale:
A. Obtaining the initial assessment of assigned clients: The initial assessment requires nursing judgment and clinical decision-making, which are within the scope of practice of a registered nurse only. It involves data interpretation and establishing a baseline for care, tasks that cannot be delegated to assistive personnel.
B. Educating a client and family members on home care: Client and family teaching requires specialized nursing knowledge to ensure understanding and accuracy. This task involves evaluating learning needs and reinforcing critical information, responsibilities that cannot be legally delegated to assistive personnel.
C. Changing a nonsterile dressing: Assistive personnel can safely perform nonsterile procedures such as changing a clean dressing under the supervision of a nurse. This task involves routine care that does not require nursing judgment, making it appropriate for delegation.
D. Interpreting a client's diagnostic laboratory results: Interpretation of laboratory data involves analysis, clinical reasoning, and the ability to make informed nursing decisions. These actions fall strictly within the nurse’s professional scope of practice and cannot be delegated to assistive personnel.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Rationale:
A. WBC count: A WBC of 13,000/mm³ is within the expected range for pregnancy, as mild leukocytosis commonly occurs due to physiologic changes, and does not require immediate reporting.
B. Fundal height: A fundal height of 27 cm at 29 weeks is slightly below average but may reflect individual variation, fetal position, or maternal factors. This finding warrants monitoring but is not an urgent concern.
C. Fetal heart rate: FHR of 158/min is within the normal range (110–160/min) for a fetus and does not indicate fetal distress, so immediate reporting is not necessary.
D. Hemoglobin: Hemoglobin of 10 g/dL is below the expected range for pregnancy (typically 11–16 g/dL). This indicates anemia, which can affect maternal and fetal oxygenation, making it important to report to the provider for further evaluation and management.
Correct Answer is D
Explanation
Rationale:
A. "Add salt to season foods.": Adding salt can irritate oral mucosa, especially in clients with AIDS who often develop stomatitis or oral candidiasis. Salty foods worsen pain and delay healing of mucosal lesions, so mild, bland foods are preferred.
B. "Eat foods served at hot temperatures.": Hot foods increase discomfort and can further damage already inflamed oral tissues. Clients should instead consume cool or room-temperature foods to soothe irritation and promote better oral intake.
C. "Rinse your mouth with an alcohol-based mouthwash.": Alcohol-based mouthwashes dry and irritate the mucous membranes, worsening oral pain and increasing the risk of bleeding or infection. Nonalcoholic rinses, such as saline or baking soda solutions, are safer alternatives.
D. "Use ice chips to numb your mouth.": Sucking on ice chips provides local numbing and temporary pain relief, allowing the client to eat and drink more comfortably. This simple intervention also helps keep the oral mucosa moist and reduces inflammation.
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