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A nurse is planning to delegate client care tasks to an assistive personnel (AP). Which of the following tasks should the nurse plan to delegate to the AP?

Perform gastrostomy feedings through a client's established gastrostomy tube

Determine if the PRN pain medication administered 30 min ago has helped

Provide instructions about client care to a family member over the telephone

Teach a client how to measure their own blood pressure

None

Answer and Explanation

The Correct Answer is A

A. This is a task that can typically be delegated to an AP, as it involves performing a routine, non-invasive procedure that does not require clinical judgment. Feeding through an established gastrostomy tube is within the scope of practice for an AP, provided the procedure is straightforward and there are no complications.
B. Incorrect. Determining if the PRN pain medication has helped is an evaluation and should bot be delegated.
C. Incorrect. Providing instructions about client care to a family member over the telephone is a task that requires clinical judgment and communication skills. The nurse should not delegate this task to an AP who might not have the knowledge or authority to answer questions or address concerns.
D. Teaching a client how to perform a health-related task, such as measuring blood pressure, requires the nurse's assessment skills and clinical judgment. Education on health tasks is a nursing responsibility and cannot be delegated to an AP.

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Correct Answer is C

Explanation

Choice A rationale:

Attaching a prefilled syringe to the catheter inflation hub is a step performed after the catheter insertion to inflate the balloon, securing the catheter in the bladder. This action is not the first step and should not be done before cleansing the meatus and positioning the sterile drape.

Choice B rationale:

Positioning the sterile drape leaving the perineum exposed is a necessary step in maintaining the sterility of the procedure area. However, it is not the first action the nurse should take. Cleaning the client's meatus with an antiseptic solution is the initial step to prevent infection during catheter insertion.

Choice C rationale:

Cleaning the client's meatus with antiseptic solution is the first step in inserting an indwelling urinary catheter. This action helps to reduce the risk of urinary tract infection by minimizing the introduction of bacteria into the urethra.

Choice D rationale:

Lubricating the catheter with water-soluble gel is a step performed after cleansing the meatus and positioning the sterile drape. It facilitates the smooth insertion of the catheter into the urethra. However, it is not the first action to be taken.

A. Providing postmortem care for a client who has recently died. B. Performing a simple dressing change on a client's foot. C. Washing hands with alcohol-based hand rub after bathing a client who has Clostridium difficile. D. Emptying an indwelling urinary catheter bag for a client while wearing clean gloves.

Correct Answer is C

Explanation

Choice A rationale:

Providing postmortem care for a client who has recently died does not require immediate intervention by the charge nurse, as it is a standard nursing responsibility to provide postmortem care with dignity and respect to the deceased client. The AP can proceed with this task independently.

Choice B rationale:

Performing a simple dressing change on a client's foot is within the scope of practice for an assistive personnel (AP) and does not require immediate intervention by the charge nurse, assuming the AP is competent and trained to perform this task.

Choice C rationale:

Washing hands with alcohol-based hand rub after bathing a client who has Clostridium difficile is not sufficient. Alcohol is not effective against C. Difficile spores.

Choice D rationale:

Clean gloves are sufficient for this task, as they do provide adequate protection against the transmission of infections.

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A nurse is planning to delegate client care tasks to an assistive personnel (AP). Which of the following tasks should the nurse plan to delegate to the AP?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to insert an indwelling urinary catheter for a client. Which of the following actions should the nurse take first?

Correct Answer is C

Explanation

A charge nurse is observing an assistive personnel perform delegated tasks. Which of the following actions by the AP requires the charge nurse to intervene?

Correct Answer is C

Explanation

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