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

Answer and Explanation

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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Correct Answer is D

Explanation

Rationale:

A. Use touch to convey acceptance: Using touch with clients who are actively hallucinating can be misinterpreted and may provoke fear or aggression. Maintaining a safe physical distance and using verbal reassurance is more appropriate during episodes of hallucination.

B. Avoid attempting to distract the client away from the hallucination: Distraction techniques are often helpful in managing hallucinations. Encouraging the client to engage in a different activity or conversation can help shift their focus away from distressing perceptual disturbances.

C. Encourage group activities: Group settings may increase anxiety or overstimulation for a client who is actively hallucinating. Individualized, low-stimulation environments are more therapeutic during acute symptoms.

D. Provide low lighting in the client's room: A calm, low-stimulation environment including dim lighting can reduce sensory overload and help the client feel more secure. Low lighting may also help minimize misinterpretation of visual stimuli that could feed into hallucinations.

A. Cleanse the most contaminated wounds first. B. Use hydrogen peroxide for wound cleaning C. Perform dressing changes every other day. D. Apply dressings with sterile gloves

Correct Answer is D

Explanation

Rationale:

A. Cleanse the most contaminated wounds first: Wound care should begin with the cleanest area and progress to the most contaminated to reduce the risk of cross-contamination. Starting with the dirtiest wounds may spread infection to cleaner sites.

B. Use hydrogen peroxide for wound cleaning: Hydrogen peroxide can damage healthy tissue and delay healing. It is generally not recommended for burn wound care due to its cytotoxic effects on granulating tissue.

C. Perform dressing changes every other day: Dressing frequency depends on the type of burn, wound condition, and healthcare provider's orders. Some burn wounds require daily or even more frequent changes to prevent infection and promote healing.

D. Apply dressings with sterile gloves: Sterile technique is critical in burn care to prevent infection. Using sterile gloves during dressing application ensures the wound is protected from external contaminants during a vulnerable healing phase.

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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?

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Naxlex Comprehensive Predictor Exams

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