A nurse is planning care for a client who has bipolar disorder and is experiencing mania.
Which of the following interventions should the nurse include in the plan?

Answer:

1. Review the skill level and qualifications of each AP.

2. Communicate appropriate tasks to the APs with specific expectations.

3. Monitor progress of task completion with each AP.

4. Evaluate the APs' performance of each task.

Explanation:

1. Review the skill level and qualifications of each AP: Before delegating tasks to the assistive personnel (APs), the nurse should assess their individual skills, training, and qualifications to determine their capabilities. This step ensures that tasks are assigned to the APs who are competent and trained to perform them safely and effectively.

2. Communicate appropriate tasks to the APs with specific expectations: The nurse should clearly communicate the tasks to be delegated to the APs, providing specific instructions and expectations regarding how each task should be performed. This step helps prevent misunderstandings and ensures that the APs understand what is expected of them.

3. Monitor progress of task completion with each AP: Once tasks are assigned, the nurse should periodically check on the progress of each AP in completing their assigned tasks. Monitoring helps the nurse ensure that tasks are being performed correctly and in a timely manner.

4. Evaluate the APs' performance of each task: After the tasks are completed, the nurse should evaluate the performance of each AP. This evaluation involves assessing whether the tasks were performed according to the specific expectations communicated earlier and whether there were any issues or deviations during task completion. The evaluation helps identify areas for improvement and provides feedback for the APs to enhance their skills and performance.

Choice A rationale:

Transferring a client to physical therapy is a task that can be safely delegated to an assistive personnel (AP) as long as the client does not have any specific medical restrictions or requires specialized assistance during the transfer. APs are trained to assist with activities of daily living, including transferring clients from one place to another. However, it is essential for the nurse to assess the client's condition and provide clear instructions to the AP to ensure a safe transfer.

Choice B rationale:

Obtaining a client's vital signs every 4 hours is a routine task that can be delegated to an assistive personnel. APs are trained to measure vital signs such as blood pressure, heart rate, respiratory rate, and temperature under the supervision of licensed healthcare providers. Regular monitoring of vital signs is crucial in assessing the client's overall health status and detecting any changes that might require immediate medical attention.

Choice E rationale:

Recording a client's intake after each meal is a task that can be delegated to an assistive personnel. APs can document the amount and type of food and fluids consumed by the client. Monitoring the client's intake is important, especially if the client has specific dietary restrictions, allergies, or medical conditions that require close monitoring of their food and fluid intake.

Choice C rationale:

Instructing a client on the use of an incentive spirometer requires specialized knowledge and assessment of the client's respiratory status. This task should be performed by a licensed healthcare provider, such as a nurse or respiratory therapist, who can properly assess the client's lung function, demonstrate the correct technique, and ensure the client's safety during the process. Delegating this task to an AP could result in improper use of the spirometer, potentially leading to complications or ineffective therapy.

Choice D rationale:

Inserting an NG tube for a client who requires enteral feedings is a complex medical procedure that should be performed by a licensed nurse or healthcare provider with appropriate training and expertise. This procedure carries risks, including the risk of aspiration if not done correctly. Delegating this task to an AP is outside their scope of practice and could jeopardize the client's safety.