A nurse is teaching an assistive personnel (AP) how to obtain a capillary finger stick blood sample. Which of the following actions by the AP requires the nurse to intervene?

Wrapping the finger in a warm cloth

Rubbing the fingertip with an alcohol pad

Puncturing the side of the fingertip

Elevating the finger above heart level

Answer and Explanation

The Correct Answer is D

A. Wrapping the finger in a warm cloth helps improve blood flow and can facilitate the blood sample collection.
B. Rubbing the fingertip with an alcohol pad cleans the site before the puncture.

C. Puncturing the side of the fingertip is less painful and avoids the pain receptors.

D. The nurse should intervene if the client elevates the finger above the level of the heart. Holding the finger below the level of the heart in a dependent position will help increase blood flow to the area and ensure an adequate specimen for collection.

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Correct Answer is A

Explanation

A. The right task involves ensuring that the delegated task is appropriate for delegation. In this case, obtaining an oral temperature should have been the correct task; however, the AP
performed the axillary temperature, indicating a deviation from the right task.
B. Right communication involves clear and effective communication between the nurse and the assistive personnel but is not directly related to the task performed.
C. Right person involves ensuring that the task is delegated to a competent and qualified

individual. The issue in this scenario is with the task itself, not the competency of the individual.

D. Right circumstance involves ensuring that the conditions are appropriate for delegation. While the circumstance is important, the primary concern in this case is the mismatch between the task and the method of temperature measurement.

A. Show the client how to use an artificial larynx. B. Arrange a support session for the client. C. Demonstrate the use of esophageal speech. D. Determine the client's reading ability.

Correct Answer is D

Explanation

A. Showing the client how to use an artificial larynx is an important aspect of post-laryngectomy care, but determining the client's reading ability takes precedence as it will significantly impact communication options.
B. Arranging a support session is important for emotional support, but assessing the client's reading ability is more immediate in addressing communication needs.
C. Demonstrating the use of esophageal speech is relevant, but understanding the client's reading ability is a priority before exploring communication alternatives.

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A nurse is teaching an assistive personnel (AP) how to obtain a capillary finger stick blood sample. Which of the following actions by the AP requires the nurse to intervene?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is delegating obtaining the collection of a client's oral temperature to an assistive personnel (AP). The nurse notes in the documentation that the AP obtained the client's axillary temperature. Which of the following rights of delegation should have prevented this situation from occurring?

Correct Answer is A

Explanation

A nurse is providing care for a client who is scheduled for a total laryngectomy. Which of the following is the nurse's priority intervention?

Correct Answer is D

Explanation

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