A nurse manager is providing an inservice program about delegation to assistive personnel (AP) with staff nurses on the unit. Which of the following statements by a staff nurse indicates an understanding of the teaching?

"The AP can re-delegate a task to another AP who has similar work experience."

"The nurse should consider the AP's level of experience when making delegation decisions."

"The nurse relinquishes accountability for client outcomes when care is delegated to an AP."

"The AP can provide client education about how to perform basic self-care to the client."

Answer and Explanation

The Correct Answer is B

A.   This statement reflects a misunderstanding of delegation principles. Typically, the original delegating nurse is responsible for ensuring that the task is completed correctly and safely. APs are not authorized to re-delegate tasks to other APs. The nurse must ensure that the task is assigned appropriately and directly to the right individual, considering their qualifications and experience.
B.   This statement demonstrates an understanding of proper delegation practices. When delegating tasks, the nurse should indeed consider the AP's level of experience and competence. Delegating tasks based on the AP's skills ensures that the tasks are performed safely and effectively, aligning with the principle that delegation should be based on the qualifications and experience of the person to whom the task is assigned.
C.   This statement reflects a misunderstanding of accountability in delegation. When a nurse delegates a task to an AP, the nurse does not relinquish accountability for client outcomes. The nurse remains accountable for ensuring that the task is delegated appropriately and that the care provided meets professional standards.
D.   This statement indicates a misunderstanding of the AP’s role. APs typically do not provide client
education, as this requires specialized knowledge and assessment skills that are within the scope of practice of licensed nurses. Client education, especially about self-care, is generally performed by registered nurses who can assess the client’s understanding and provide detailed instructions.

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Correct Answer is C

Explanation

A. While a severe migraine headache is certainly uncomfortable and may require medication and observation, it does not typically necessitate constant monitoring. The client might benefit from a quieter room and can often be managed effectively with scheduled visits by nursing staff. Therefore, this client does not necessarily need to be closest to the nurses' station.
B. A client with a suspected diagnosis of TB should be placed in a negative-pressure isolation room to prevent the spread of airborne pathogens. The proximity to the nurses' station is less critical for infection control purposes. Proper isolation procedures and equipment are more important for managing TB.
C. A client with a head injury and periods of confusion is at risk for complications such as falls, disorientation, or worsening of their condition. This client requires close monitoring to ensure their safety and to promptly address any changes in their condition. Assigning this client to a room closest to the nurses' station ensures that the staff can frequently observe and quickly respond to any potential issues.

D. A client on continuous ECG monitoring requires regular assessment of their heart rhythm and immediate intervention if there are any abnormalities. While close monitoring is needed, this client’s condition is managed with electronic equipment that can alert staff to significant changes, so proximity to the nurses' station is less critical compared to more acute or unpredictable conditions.

A. Case manager B. Respiratory therapist C. Diabetes nurse educator D. Physical therapist E. Occupational therapist F. Enterostomal therapy nurse

Correct Answer is ["A","B","D","E"]

Explanation

A. A case manager coordinates and manages the overall care of the client, particularly when there are multiple healthcare needs or transitions in care. Given that the client has just experienced a CVA, the case manager could be crucial in coordinating care, arranging for additional services, and ensuring continuity of care, especially since the client lives alone.
B. The client is experiencing wheezing in the upper lobes of the lungs and is receiving supplemental oxygen. A respiratory therapist would be instrumental in evaluating and managing the client's respiratory status, including optimizing oxygen therapy and addressing any issues related to asthma or lung function.
C. There is no mention of diabetes in the client's history or current symptoms. The focus of the client's care is on managing the effects of the CVA and respiratory issues. Therefore, a referral to a diabetes nurse educator is not indicated based on the provided information.
D. The client has flaccid extremities with decreased muscle tone and strength following the CVA. A physical therapist would be essential for assessing and providing therapy to improve mobility, strength, and function in the affected extremities. This referral is appropriate for addressing the physical impairments resulting from the CVA.
E. The client is having difficulty with self-feeding due to decreased muscle tone and strength, which impacts daily activities. An occupational therapist can help with adaptive techniques and strategies for self-care tasks, such as feeding, and provide interventions to improve the client’s ability to perform daily activities independently. This referral is appropriate for addressing functional challenges related to the CVA.
F. An enterostomal therapy nurse specializes in wound care, ostomy management, and incontinence care. There is no indication in the provided information that the client has any issues related to wounds, ostomies, or incontinence. Therefore, a referral to an enterostomal therapy nurse is not indicated based on the current information.

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A nurse manager is providing an inservice program about delegation to assistive personnel (AP) with staff nurses on the unit. Which of the following statements by a staff nurse indicates an understanding of the teaching?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A charge nurse is anticipating the admission of four clients and planning their room assignments. Which of the following clients should the nurse assign to the room closest to the nurses' station?

Correct Answer is C

Explanation

A nurse is caring for a client. Exhibits For which of the following interprofessional team members should the nurse anticipate a provider's referral? (Select all that apply).

Correct Answer is ["A","B","D","E"]

Explanation

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