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 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."
"You can delegate this task to an AP for new clients before performing a nursing assessment.”
The Correct Answer is A
A. Weighing clients is within the scope of an assistive personnel’s role, provided they have been properly trained in using facility equipment and understand the procedure. The nurse retains responsibility for ensuring the accuracy of the data and interpreting it.
B. This response focuses on the nurse’s ability rather than appropriate delegation. Delegating tasks helps manage time and resources effectively when delegation is safe and appropriate.
C. Weighing clients does not require nursing judgment; it is a routine, stable task that is appropriate for delegation under the right conditions.
D. Weights obtained on new clients may be needed before a full nursing assessment, but initial assessments must be performed by a nurse, not delegated to APs.
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Related Questions
Correct Answer is C
Explanation
A. "Why do you think your partner's symptoms are progressing so quickly?” This question can feel blaming and may cause the partner to become defensive, which is not therapeutic. This response shifts the burden of explanation to the partner and doesn't directly address their expressed feeling of being overwhelmed.
B. “You did the right thing by bringing your partner in for treatment.” While supportive, this statement shuts down further discussion and does not encourage the partner to express feelings or concerns.
C. “Can you talk about what was happening with your partner at home.” This open-ended question encourages the partner to share feelings and experiences, fostering communication and therapeutic rapport.
D. “You should make sure your partner takes the prescribed medication.” This response is prescriptive and shifts immediately to an action plan without first acknowledging or exploring the partner's current emotional state and the overwhelming situation they are describing. .
Correct Answer is C
Explanation
A. Insert an indwelling urinary catheter: This may be necessary to monitor fluid output after diuretic therapy, but it is not the immediate priority when oxygenation is compromised due to fluid in the lungs.
B. Administer an IV diuretic: Diuretics help reduce fluid overload, which is key in managing pulmonary edema, but oxygenation must be addressed first to stabilize the client and prevent hypoxia.
C. Initiate oxygen via face mask: The most urgent concern in acute pulmonary edema is impaired gas exchange. Administering oxygen immediately helps improve oxygenation and is the priority intervention to address life-threatening hypoxia.
D. Request an analysis of ABGs: While ABG results are important to assess respiratory function and guide further treatment, drawing labs takes time. Oxygen administration should not be delayed in order to obtain lab values.
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