A nurse is preparing to delegate client care to an assistive personnel (AP). Which of the following information should the nurse verify prior to delegation?
The client's length of facility stay
The AP's job description
The AP's years of experience
The client's age
The Correct Answer is B
Rationale:
A. The client's length of facility stay: The duration of a client’s admission does not determine the appropriateness of delegation. Delegation decisions are based on the client’s current condition and the nature of the task, not how long they have been in the facility.
B. The AP's job description: Verifying the AP’s job description ensures the task falls within their authorized scope of practice. It helps confirm that the AP has the appropriate training and legal authority to carry out the delegated activity safely and competently.
C. The AP's years of experience: While experience may influence efficiency, it is not the primary factor in deciding what can be delegated. A newly trained AP may be competent for certain tasks, while years of experience do not guarantee suitability for all delegated care.
D. The client's age: Age alone does not dictate whether a task can be delegated. Delegation decisions depend more on the client's acuity, stability, and the complexity of care required, rather than demographic factors like age.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Rationale:
A. Apply a warm compress: Applying a warm compress may help promote absorption of infiltrated fluid and reduce discomfort, but it should not be the initial action. Warm compresses are appropriate only after the infusion is stopped and proper assessment is completed.
B. Stop the infusion: The first priority when infiltration is suspected—evidenced by cool, edematous skin—is to stop the infusion immediately. Continuing the infusion could lead to worsening tissue damage or complications depending on the type of fluid or medication.
C. Document the infiltration: Documentation is necessary but not the immediate priority. It should follow prompt clinical action to stop the infusion and prevent further harm to the surrounding tissue.
D. Elevate the arm: Elevating the arm can help reduce edema, but this supportive measure should be done only after the infusion has been stopped. It does not address the root cause or prevent further infiltration.
Correct Answer is B
Explanation
Rationale:
A. Cleanse the perineum with 0.9% sodium chloride after bowel movements: While perineal hygiene is important postpartum, cleansing with normal saline is more routine care and does not specifically target endometritis management.
B. Obtain serial blood cultures: Endometritis is a uterine infection that can lead to bacteremia or sepsis. Serial blood cultures help identify the causative organism and guide antibiotic therapy.
C. Insert and maintain an indwelling urinary catheter: Indwelling catheters increase the risk of urinary tract infections and are not routinely used unless there is urinary retention or other specific indications.
D. Encourage the use of a sitz bath twice a day: Sitz baths promote perineal comfort and hygiene but do not directly treat uterine infections like endometritis. They may be recommended for perineal pain but are not primary treatment for endometritis.
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