A nurse is preparing to delegate tasks to an assistive personnel after receiving change-of-shift report. The nurse should assign the AP to obtain vital signs from which of the following clients?

A client who has just returned from the PACU

A client who has a blood pressure of 110/68 mm Hg

A client who is experiencing chest pain

A client who has a fasting blood glucose of 104 mg/dL

Answer and Explanation

The Correct Answer is B

a. A client who has just returned from the PACU:

Vital signs for a client who has just returned from the Post-Anesthesia Care Unit (PACU) are usually obtained by licensed nursing staff due to the potential for complications and the need for close monitoring.

b. A client who has a blood pressure of 110/68 mm Hg:

This client has stable vital signs, and obtaining blood pressure measurements within normal range is a routine task suitable for delegation to assistive personnel.

c. A client who is experiencing chest pain:

Clients experiencing chest pain require immediate assessment by licensed nursing staff or a healthcare provider. This is not a task appropriate for delegation to assistive personnel.

d. A client who has a fasting blood glucose of 104 mg/dL:

Monitoring blood glucose levels is typically within the scope of licensed nursing staff. Delegating tasks related to clients with diabetes or glucose monitoring to assistive personnel may not be appropriate.

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Correct Answer is C

Explanation

a. Help the AP assist the client with the transfer.

While it is important to instruct the AP to seek assistance when unsure, this does not immediately address the safety of the client during the current incorrect transfer.

b. Demonstrate the proper client transfer technique to the AP.

Demonstrating the proper technique is an important step, but it should come after ensuring the immediate safety of the client. This can be done once the client is safely transferred.

c. Instruct the AP to request assistance when unsure about a task.

Correct. The nurse's first priority should be the safety of the client. By immediately assisting the AP with the transfer, the nurse ensures the client's safety and prevents potential injury.

d. Refer the AP to the facility procedure manual.

Referring the AP to the procedure manual is important for future reference, but it does not address the immediate risk to the client. This action can be taken after ensuring the client's safety and demonstrating the correct technique.

A. Advise him to complete less time-consuming tasks first B. Recommend that he take time to plan at the beginning of his shift C. Offer to provide care for his clients while he takes a break D. Ask other staff members to take over some of his tasks

Correct Answer is B

Explanation

a. Advise him to complete less time-consuming tasks first:

This intervention may be helpful in prioritizing tasks and ensuring that essential care is provided in a timely manner. However, it does not address the underlying issue of difficulty focusing and may not address the root cause of the problem.

b. Recommend that he take time to plan at the beginning of his shift:

Planning at the beginning of the shift is essential for organizing tasks and prioritizing care. This intervention may help the newly licensed nurse improve their time management skills and focus by providing a structured approach to their work.

c. Offer to provide care for his clients while he takes a break:

While taking breaks is important for maintaining focus and preventing burnout, offering to provide care for his clients may not address the underlying issue of difficulty focusing and completing tasks. Additionally, taking over his tasks may not encourage the newly licensed nurse to develop the skills needed to improve his performance.

d. Ask other staff members to take over some of his tasks:

Asking other staff members to take over some of his tasks may provide temporary relief, but it does not address the underlying issue or help the newly licensed nurse develop the skills needed to improve his performance.

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A nurse is preparing to delegate tasks to an assistive personnel after receiving change-of-shift report. The nurse should assign the AP to obtain vital signs from which of the following clients?

Nursing Test Bank

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