A nurse is preparing to delegate bathing and turning of a newly admitted client who has end- stage bone cancer to an experienced assistive personnel (AP). Which of the following assessments should the nurse make before delegating care?
Is the client's family present so the AP can show them how to turn the client?
Has the AP checked the client's pain level prior to turning her?
Does the AP have time to change the client's central IV line dressing after turning her?
Has data been collected about specific client needs related to turning?
The Correct Answer is D
A. While involving the family might be beneficial for education, it's not directly related to assessing the client's needs for turning.
B. Assessing the client's pain level is important, but it's only one aspect of comprehensive care when delegating turning to the AP.
C. Checking the AP's availability for other tasks after turning the client is important but not the primary assessment before delegation.
D. Before delegating care, the nurse should assess and collect data about the client's specific needs related to turning due to the client's condition. Understanding the client's condition and requirements for turning is crucial for effective delegation.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Collaborative, user-edited websites might contain varying levels of accuracy and reliability regarding medical information, making them less suitable for obtaining specific prevalence data.
B. An evidence-based nursing journal is a reliable source of information that often includes statistical data, prevalence rates, and updated research on various medical conditions, including Tay-Sachs disease.
C. The facility's case manager might have general information but may not provide specific prevalence rates for Tay-Sachs disease.
D. While the client's health care provider might have knowledge about Tay-Sachs disease, their primary focus during a clinical encounter might be the client's immediate care needs rather than providing statistics on disease prevalence.
Correct Answer is A
Explanation
A. Asking the client's son to go to the waiting area allows the nurse to have a private conversation with the client, which is crucial in suspected cases of elder abuse to gather information without potential interference or intimidation.
B. Asking about injuries with the son present might hinder the client from disclosing information due to fear or pressure.
C. Treating and discharging the client without addressing the suspected elder abuse could potentially put the client in further danger.
D. Filing an incident report might be necessary but should follow an assessment and investigation of the situation.
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