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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Waiting to dispose of sharps containers until they are completely full might compromise safety and infection control practices.
B. Using clean gloves rather than sterile gloves for colostomy care is a possible interventin that can be applied.
C. Returning unused supplies to the unit's supply stock is not correct.
D. Storing opened bottles of normal saline for up to 48 hours might not be compliant with storage guidelines and could risk contamination, potentially increasing costs through wastage or patient harm.
Correct Answer is C
Explanation
A. Contacting the provider may be part of the process, but it does not directly address the conflict between the family members' wishes and the health care surrogate's legal authority.
B. While the ethics committee can be a valuable resource in resolving disputes, it is not the first step in this situation, as the health care surrogate has the legal right to make decisions on behalf of the unconscious client.
C. The health care surrogate is legally designated to make health care decisions for the client when they are unable to do so themselves. This includes decisions about life-sustaining treatments such as a feeding tube.
D. Reviewing the client's advance directives is important, but it does not supersede the authority of the health care surrogate unless the directives explicitly limit the surrogate's decision-making power.
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