A nurse is planning to delegate client assignments to an assistive personnel. Which of the following tasks is appropriate for the nurse to delegate?

Collecting a urine specimen

Measuring a client's pain level

Monitoring blood glucose levels

Adjusting the flow rate of a client's oxygen tank

Answer and Explanation

The Correct Answer is A

A. Collecting a urine specimen: This task is routine, noninvasive, and does not require nursing judgment, making it appropriate for delegation to assistive personnel. APs are trained to obtain clean-catch or routine urine specimens while following proper technique. Delegating this task allows the nurse to focus on interventions requiring professional judgment.

B. Measuring a client's pain level: Pain assessment requires clinical judgment and involves interpreting verbal and nonverbal cues. Determining the severity, characteristics, and impact of pain is a nursing responsibility. Because it directly influences clinical decisions and interventions, it cannot be delegated to assistive personnel.

C. Monitoring blood glucose levels: Although APs in some settings may perform point-of-care glucose checks, this task generally requires specific training and competency validation. Interpretation of results and subsequent actions rely on nursing assessment, making it less appropriate for routine delegation unless the facility has clear protocols allowing it.

D. Adjusting the flow rate of a client's oxygen tank: Oxygen therapy adjustment involves evaluating the client’s respiratory status and making changes that can affect ventilation and oxygenation. Altering flow rates requires nursing judgment to ensure safety and prevent complications such as hypoxia or CO₂ retention.

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Correct Answer is C

Explanation

A. Rupture the amniotic sac: Artificial rupture of membranes is contraindicated in complete placenta previa because it can trigger severe maternal hemorrhage due to placental location over the cervical os.

B. Medicate the client for pain: While pain management may be necessary, the immediate priority is maternal and fetal safety. Pain control does not address the life-threatening risk of bleeding with placenta previa.

C. Prepare the client for a cesarean section: Complete placenta previa requires delivery by cesarean section to prevent catastrophic hemorrhage. Preparing for surgery is the priority intervention for both maternal and fetal safety.

D. Perform a vaginal exam: Vaginal examination is contraindicated in complete placenta previa because it can disrupt the placenta and cause severe bleeding. It should not be performed.

A. Assess the client for triggers of self-mutilating behavior. B. Encourage the client to use splitting behaviors. C. Assist the client in developing more dependent relationships. D. Use sympathy when developing the therapeutic relationship with the client

Correct Answer is A

Explanation

A. Assess the client for triggers of self-mutilating behavior: Clients with borderline personality disorder are at risk for self-harm. Identifying triggers helps the nurse implement preventive strategies, provide timely interventions, and promote safety, which is a critical component of care planning.

B. Encourage the client to use splitting behaviors: Splitting, or viewing people as all good or all bad, is a maladaptive coping mechanism. Encouraging this behavior would worsen interpersonal relationships and is not therapeutic.

C. Assist the client in developing more dependent relationships: Borderline personality disorder involves unstable and intense interpersonal relationships. Promoting dependence is counterproductive; the goal is to foster healthy, balanced relationships and coping strategies.

D. Use sympathy when developing the therapeutic relationship with the client: Sympathy can reinforce maladaptive behaviors and dependency. Therapeutic relationships should focus on empathy, consistency, and clear boundaries rather than sympathy.

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A nurse is planning to delegate client assignments to an assistive personnel. Which of the following tasks is appropriate for the nurse to delegate?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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