A nurse is teaching a newly licensed nurse about delegating tasks to assistive personnel. Which of the following statements should the nurse make?

“You can ask an AP to teach a simple task to a client.”

“You should assign tasks you are unfamiliar with to an experienced AP.”

“If you are unsure about an AP’s ability, observe them performing the task.”

“The person who delegates a task is not held accountable for the outcome.”

Answer and Explanation

The Correct Answer is C

a. "You can ask an AP to teach a simple task to a client."

While assistive personnel may assist with client education under the supervision of a licensed nurse, the primary responsibility for teaching tasks to clients usually rests with licensed healthcare providers.

b. "You should assign tasks you are unfamiliar with to an experienced AP."

Delegating tasks to assistive personnel should be based on their competency and the complexity of the task, not necessarily on the nurse's familiarity with it. It is essential to delegate tasks that the AP is trained and competent to perform.

c. "If you are unsure about an AP’s ability, observe them performing the task."

This is the correct statement. It emphasizes the importance of assessing an assistive personnel's competence by observing their performance before delegating tasks, especially if there is uncertainty about their abilities.

d. "The person who delegates a task is not held accountable for the outcome."

This statement is incorrect. The person delegating a task is ultimately accountable for ensuring that the task is performed correctly and safely. Delegation does not relieve the delegator of accountability.

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Correct Answer is A

Explanation

a. Institute rounds every 2 hr. during the day to offer toileting:

This intervention is appropriate as it helps address the need for toileting assistance, which can reduce the risk of falls associated with residents attempting to ambulate to the bathroom independently. Regular toileting rounds can help prevent falls related to toileting urgency or difficulty.

b. Keep four side rails up on the beds at night:

Keeping all four side rails up on the beds can increase the risk of entrapment and may not be necessary for all residents. Using bed rails should be individualized based on each resident's risk assessment and should follow facility policies and guidelines to prevent entrapment and ensure resident safety.

c. Apply vest restraints on the residents who are confused:

Using restraints, such as vest restraints, should be avoided whenever possible due to the increased risk of physical and psychological harm to residents. Restraints do not address the underlying causes of falls and can contribute to agitation, loss of mobility, and pressure injuries.

d. Accompany residents older than 85 years of age during ambulation:

This intervention is appropriate, especially for residents who are at increased risk of falls, such as those over 85 years of age. Accompanying residents during ambulation allows for assistance and support, reduces the risk of falls, and provides an opportunity for early intervention if balance or mobility issues arise.

A. Ask the client if she would like a sedative to help her relax B. Inform the client that she cannot leave without a discharge prescription from the provider C. Have the client sign the Against Medical Advice form D. Assign a security officer to the client’s room until the provider can speak with the client

Correct Answer is C

Explanation

a. Ask the client if she would like a sedative to help her relax:

Offering a sedative may not address the underlying reasons for the client's desire to leave. Moreover, administering a sedative without addressing the client's concerns or obtaining informed consent would not be appropriate.

b. Inform the client that she cannot leave without a discharge prescription from the provider:

While informing the client of the discharge process is important, presenting this information as a restriction may not be the most therapeutic approach. Additionally, in many healthcare settings, patients have the legal right to leave against medical advice, so presenting it as a requirement may not be accurate.

c. Have the client sign the Against Medical Advice form:

When a client decides to leave against medical advice, it is standard practice to have them sign an Against Medical Advice (AMA) form. This form documents the client's decision and acknowledges that they are leaving the hospital against the advice of the healthcare provider.

d. Assign a security officer to the client's room until the provider can speak with the client:

Assigning a security officer may be appropriate in situations where there are concerns for the safety of the client or others, such as if the client is agitated or threatening harm. However, in this scenario, the client has expressed a desire to leave, and assigning a security officer may escalate the situation unnecessarily.

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A nurse is teaching a newly licensed nurse about delegating tasks to assistive personnel. Which of the following statements should the nurse make?

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