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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Rationale:
A. Projectile vomiting: Projectile vomiting is more commonly associated with pyloric stenosis in infants, not intussusception. While vomiting may occur in intussusception, it is typically bilious and not forceful or projectile in nature.
B. Periorbital edema: Periorbital edema is typically related to renal or allergic conditions such as nephrotic syndrome or severe allergic reactions. It is not associated with gastrointestinal issues like intussusception.
C. Stools that contain currant jelly-like mucus: Intussusception causes bowel telescoping, leading to obstruction and compromised blood flow. This results in stools containing blood and mucus, often described as “currant jelly,” which is a hallmark symptom of the condition.
D. Visible gastric peristaltic waves: Visible peristalsis is more indicative of pyloric stenosis, where there is hypertrophy of the pyloric muscle. It is not typically seen in cases of intussusception.
Correct Answer is B
Explanation
Rationale:
A. Urinary retention: Urinary retention is a potential side effect of epidural anesthesia due to blockade of sacral nerves, not necessarily a sign of unrelieved pain. It may occur even if pain is well managed, especially with regional anesthetics affecting bladder function.
B. Restlessness: Restlessness is a common behavioral indicator of unrelieved pain. When verbal reporting is limited or unreliable, restlessness may reflect discomfort, agitation, or anxiety related to inadequate pain control following procedures such as epidural administration.
C. Difficulty swallowing: Difficulty swallowing is not associated with pain from a herniated disc or the effects of an epidural. It may instead suggest upper airway or neurologic issues and should prompt assessment for complications unrelated to pain control.
D. Constipation: Constipation is more commonly linked to opioid use or immobility rather than unrelieved pain. While discomfort may contribute, constipation alone does not reliably indicate the adequacy of pain relief in clients receiving an epidural.
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