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. “Remain on bed rest for 24 hours following the procedure.”: Prolonged bed rest increases the risk of venous stasis and deep vein thrombosis, so this instruction does not promote circulation and is not recommended.
B. “Place a pillow under your knees while in bed.”: Elevating the knees can impede venous return and increase the risk of blood clots, so this practice is discouraged for circulation promotion.
C. “Participate in range-of-motion exercises.”: Performing range-of-motion exercises helps stimulate blood flow, reduce venous stasis, and promote circulation, which is essential during the postoperative period to prevent complications.
D. “Use an incentive spirometer every 4 hours.”: Using an incentive spirometer improves lung expansion and oxygenation but does not directly promote circulation in the extremities.
Correct Answer is A
Explanation
A. Methylprednisolone: This corticosteroid is commonly used to reduce inflammation in conditions like pneumonia. One of its known adverse effects is hyperglycemia, especially during stress or infection, due to its role in increasing gluconeogenesis and decreasing peripheral glucose uptake.
B. Ondansetron: This antiemetic is used to prevent nausea and vomiting. It does not significantly affect blood glucose levels and is not associated with hyperglycemia as an adverse effect.
C. Guaifenesin: As an expectorant, guaifenesin helps loosen mucus in the airways but has no known effect on glucose metabolism. It is not linked to elevated blood glucose in clinical use.
D. Amoxicillin: This antibiotic is effective in treating bacterial pneumonia but does not impact glucose levels. Hyperglycemia is not a typical adverse effect of this medication.
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