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.”

Answer and Explanation

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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Correct Answer is D

Explanation

A. Warm the irrigation solution: While warming may enhance comfort, it does not impact the color of urine or address post-procedure bleeding. It is not a necessary intervention in this situation.
B. Perform the Credé's maneuver: This technique, which involves manual pressure over the bladder, is used for clients with neurogenic bladder or urinary retention. It is not appropriate during continuous bladder irrigation.
C. Replace the indwelling urinary catheter: Catheter replacement would only be considered if there was a complete blockage that couldn't be cleared, severe kinking, or signs of infection, none of which are indicated here. Replacing the catheter unnecessarily increases the risk of trauma and infection.
D. Maintain the irrigation solution rate: Pink-tinged urine is expected within the first few hours following TURP as a result of minor bleeding. Continuing irrigation at the current rate helps prevent clot formation and maintains catheter patency.

A. Instruct the client to wash her hands before and after changing her perineal pad. B. Initiate contact precautions. C. Monitor the height and tone of the client's fundus. D. Encourage the client to maintain a semi-Fowler's position to enhance uterine drainage. E. Inform the client she will need to formula feed her newborn until she has received antibiotics for 24 hr. F. Request a prescription for terbutaline from the provider. G. Obtain a culture specimen of the lochia from the client's perineal pad using a sterile swab.

Correct Answer is ["A","C","D"]

Explanation

A. Instruct the client to wash her hands before and after changing her perineal pad: Good perineal hygiene is essential in preventing the spread or worsening of infection, especially when endometritis is suspected.
B. Initiate contact precautions: Contact precautions are not necessary for endometritis, which is not a contagious condition. Standard precautions are sufficient.
C. Monitor the height and tone of the client's fundus: Fundal assessment is important to detect uterine atony and evaluate the response to methylergonovine, which is prescribed to improve uterine tone and reduce postpartum bleeding.
D. Encourage the client to maintain a semi-Fowler's position to enhance uterine drainage: This position promotes lochial drainage and prevents pooling of infected discharge in the uterine cavity, supporting infection resolution.
E. Inform the client she will need to formula feed her newborn until she has received antibiotics for 24 hr: Most antibiotics used for postpartum infections, including clindamycin, are compatible with breastfeeding. Breastfeeding is usually encouraged unless contraindicated.
F. Request a prescription for terbutaline from the provider: Terbutaline is a tocolytic used to relax the uterus in preterm labor, not to treat postpartum infection or improve uterine tone. Methylergonovine is already prescribed for uterine tone enhancement.
G. Obtain a culture specimen of the lochia from the client's perineal pad using a sterile swab: Cultures from a perineal pad may be contaminated. If needed, endometrial cultures are obtained using a sterile technique via the cervix.

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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?

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Correct Answer is D

Explanation

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Correct Answer is ["A","C","D"]

Explanation

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