A nurse is training a newly licensed nurse. The newly licensed nurse asks if she can delegate the task of weighing several clients to an assistive personnel (AP). Which of the following responses should the nurse make?

"You can delegate this task if the AP has been trained to use our scales."

"You can delegate this task to an AP for new clients before performing a nursing assessment."

"You should not delegate this task because you have the capability to obtain clients' weights."

"You should not delegate this task because it requires nursing judgment."

Answer and Explanation

The Correct Answer is A

A. "You can delegate this task if the AP has been trained to use our scales.": Measuring and recording client weight is a noninvasive, routine task that does not require nursing judgment, making it appropriate to delegate to trained assistive personnel. The nurse remains responsible for ensuring accuracy and proper documentation.

B. "You can delegate this task to an AP for new clients before performing a nursing assessment.": Delegating weight measurement before a nursing assessment may result in incomplete or inaccurate data interpretation. Initial assessments require nursing judgment to identify baseline health status.

C. "You should not delegate this task because you have the capability to obtain clients' weights.": Possessing the ability to perform a task does not preclude delegation. The key consideration is whether the task requires professional judgment, which measuring weight does not.

D. "You should not delegate this task because it requires nursing judgment.": Obtaining a client’s weight is a standard, objective measurement and does not require clinical decision-making, so it does not meet the criteria for tasks that must be performed exclusively by a nurse.

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Correct Answer is A

Explanation

A. "This test should be performed after your baby is 24 hours old.": Newborn genetic screening is ideally performed after 24 hours of life to ensure accurate detection of metabolic and endocrine disorders. Performing the test too early can result in false-negative results due to insufficient accumulation of metabolites in the blood.

B. "A nurse will draw blood from your baby's inner elbow.": Newborn screening is typically performed via a heel stick, not from the inner elbow. The lateral or plantar aspect of the heel provides safe access to capillary blood for accurate testing.

C. "Your baby will be given 2 ounces of water to drink prior to the test.": Newborns are not given water prior to screening. Water administration is unnecessary and could be harmful, as infants should receive breast milk or formula to meet hydration needs.

D. "This test will be repeated when your baby is 2 months old.": While some repeat testing may occur if initial results are inconclusive, routine newborn genetic screening is performed once after 24 hours of life, not automatically repeated at 2 months.

A. "We should establish our roles in the initial session." B. "Let me show you simple relaxation exercises to manage stress." C. "We should discuss resources to implement in your daily life." D. "Let's talk about how you can change your response to stress."

Correct Answer is A

Explanation

A. "We should establish our roles in the initial session.": During the orientation phase of the therapeutic relationship, the nurse and client define the purpose of the relationship, clarify roles, and establish trust. Setting clear expectations helps the client feel safe and provides a framework for subsequent therapeutic work.

B. "Let me show you simple relaxation exercises to manage stress.": Teaching relaxation techniques occurs in the working phase of the therapeutic relationship, when the client is actively addressing anxiety symptoms and developing coping strategies. It is not the focus during orientation.

C. "We should discuss resources to implement in your daily life.": Discussing resources and practical interventions is part of the working or termination phase, after rapport has been established and the client is ready to apply strategies outside the therapeutic setting.

D. "Let's talk about how you can change your response to stress.": Exploring behavioral change and coping strategies is a component of the working phase. The orientation phase is intended for establishing trust, setting goals, and defining roles rather than implementing interventions.

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A nurse is training a newly licensed nurse. The newly licensed nurse asks if she can delegate the task of weighing several clients to an assistive personnel (AP). Which of the following responses should the nurse make?

Nursing Test Bank

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