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 A
Explanation
A. Arrange for an ethics committee meeting to address the family’s concerns: When there is a conflict between advance directives and family wishes, an ethics committee can help mediate and ensure the client’s legal rights and wishes are upheld while addressing the family's concerns.
B. Support the family's decision and initiate life-sustaining measures: Following the family’s request instead of the client’s legally documented advance directives violates the client’s autonomy and can result in legal and ethical consequences.
C. Complete an incident report: An incident report is used for errors or unexpected events, not for resolving ethical conflicts involving advance directives and treatment decisions.
D. Encourage the family to contact an attorney: While the family has the right to seek legal counsel, the nurse's role is to advocate for the client's documented wishes and follow institutional procedures for resolving disputes.
Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"B"}
Explanation
Rationale for Correct Options:
- Apply oxygen via nasal cannula: The client is experiencing shallow respirations, SPO2 92%, lethargy, low urine output, and decreased DTRs, which are classic signs of magnesium sulfate toxicity. Administering oxygen helps improve oxygenation and mitigate hypoxia while preparing for further intervention.
- Calcium gluconate: This is the antidote for magnesium sulfate toxicity. Given the client’s clinical signs such as depressed DTRs, lethargy, and shallow breathing, immediate preparation and administration of calcium gluconate is essential to reverse potentially life-threatening effects.
Rationale for Incorrect Options:
- Reduce fluid intake: Although urine output is decreased, the primary concern is not fluid overload but rather signs of magnesium toxicity. Fluid restriction would not address the current emergent symptoms.
- Discontinue IV infusion: Magnesium sulfate infusion should be discontinued if toxicity is suspected, but it's not the first action compared to applying oxygen. The infusion should be stopped as soon as respiratory support is provided.
- Hydralazine: While this antihypertensive can treat severe hypertension in pregnancy, it is not the immediate priority in the setting of magnesium toxicity. Stabilizing respiratory and neurologic status takes precedence.
- Nifedipine: This antihypertensive has already been prescribed and possibly administered earlier. Re-administering it would not be the correct response to signs of magnesium toxicity, and could exacerbate hypotension or bradycardia.
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