A nurse is planning care for a client who has Addison's disease. Which of the following tasks should the nurse plan to delegate to an assistive personnel?
Explain to the client about a 24-hr urine specimen collection.
Remind the client to change positions slowly.
Determine the client's muscle strength prior to ambulation.
Decide how often to measure vital signs.
The Correct Answer is B
Rationale:
A. Explaining a 24-hr urine specimen collection requires teaching, which is a nursing responsibility and cannot be delegated to assistive personnel (AP).
B. Reminding the client to change positions slowly is reinforcement of prior teaching and is appropriate to delegate to an AP.
C. Determining muscle strength requires assessment, which is the nurse’s responsibility and cannot be delegated.
D. Deciding how often to measure vital signs involves nursing judgment and care planning, which cannot be delegated to an AP.
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Related Questions
Correct Answer is C
Explanation
Rationale:
A Visitors for a client on contact precautions (e.g., MRSA, C. diff) need gloves and gown, not a mask, unless droplet or airborne precautions are also indicated.
B. A client with compromised immunity requires protective isolation in a positive-pressure airflow room, not a negative-pressure one (which is for airborne infections).
C. Clients on airborne precautions (e.g., TB, measles, varicella) must wear a surgical mask if they leave their room to prevent spreading infectious particles.
D. An N95 respirator is used for airborne precautions, not droplet. Droplet precautions (e.g., influenza, pertussis) only require a surgical mask within 3 feet of the client.
Correct Answer is D
Explanation
Rationale:
A. Reviewing facility policies is important but should follow understanding the underlying cause of the issue.
B. Discussing time management strategies may be helpful but is premature without knowing why breaks are being missed.
C. Providing coverage for breaks is a possible solution, but it should be based on identified barriers.
D. Determining the reasons the nurses are not taking breaks is the first step, as it allows the charge nurse to address the root cause and implement an appropriate and effective solution.
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