A nurse is planning to assign care activities to the assistive personnel (AP) on her team. Which of the following activities can the nurse assign to the AP? (Select all that apply.)

Check the position of a client in soft wrist restraints.

Accompany a client who has depression to occupational therapy.

Set limits with a client who has mania.

Sit with a client who has alcohol use disorder and whose last drink was five days ago.

Assess a client who has hypomania for exhaustion.

Answer and Explanation

Correct Answer : A,B,D

Rationale:

A. Check the position of a client in soft wrist restraints is appropriate for an AP as it involves routine monitoring and ensuring the client's safety.

B. Accompany a client who has depression to occupational therapy is a task that can be assigned to an AP, as it involves providing support and ensuring the client's safe arrival to therapy.

C. Set limits with a client who has mania is not appropriate for an AP, as this involves therapeutic communication and behavior management, which requires nursing judgment.

D. Sit with a client who has alcohol use disorder and whose last drink was five days ago can be assigned to an AP as it involves providing a supportive presence and monitoring, but the nurse should assess for withdrawal symptoms.

E. Assess a client who has hypomania for exhaustion is a nursing responsibility that involves evaluation and judgment, making it inappropriate to delegate to an AP.

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Correct Answer is A

Explanation

Rationale:

A. Check the client's medical record for the provider's prescription is the appropriate action to confirm whether the enema was indeed ordered and to ensure that the client’s concerns are addressed.

B. Inform the charge nurse that the client refused the enema might be premature without first verifying the order and addressing the client's concerns.

C. Explain to the client that the provider prescribed the procedure is not appropriate if you have not confirmed the order. It may be premature if the order is not documented.

D. Assure the client that enemas are commonly prescribed for constipation does not address the client’s specific concern about whether the enema was actually ordered.

A. Nonmaleficence B. Veracity C. Autonomy D. Fidelity

Correct Answer is A

Explanation

A. Nonmaleficence: By completing a critical care and emergency nursing course before transferring to the ICU, the nurse is ensuring they are adequately prepared to care for critically ill clients. This action minimizes the risk of harm caused by a lack of knowledge or skill, demonstrating adherence to the principle of nonmaleficence.

B. Veracity: Veracity refers to truthfulness and honesty in interactions with clients and colleagues. While important, this scenario does not focus on providing truthful information.

C. Autonomy: Autonomy refers to respecting a client's right to make decisions about their care. This scenario does not involve supporting or promoting client decision-making.

D. Fidelity: Fidelity refers to being faithful to commitments and promises made to clients or the profession. While the nurse is demonstrating professional responsibility, this scenario aligns more closely with nonmaleficence than fidelity.

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A nurse is planning to assign care activities to the assistive personnel (AP) on her team. Which of the following activities can the nurse assign to the AP? (Select all that apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to administer a soap suds enema to a client who has constipation. As the nurse explains the procedure, the client states, "The doctor didn't tell me I was supposed to receive an enema." Which of the following nursing actions is appropriate at this time?

Correct Answer is A

Explanation

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Correct Answer is A

Explanation

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