A nurse on a medical-surgical unit is assigning tasks to an assistive personnel (AP). Which of the following tasks should the nurse delegate to the AP?
Performing indwelling urinary catheter care
Demonstrating how to use an incentive spirometer
Measuring the depth of a stage 3 pressure injury
Changing the appliance on a new colostomy
The Correct Answer is A
Delegating tasks involves assigning appropriate responsibilities to assistive personnel based on their level of training, competency, and scope of practice. Performing indwelling urinary catheter care is a task that can be safely delegated to an AP who has received proper training and demonstrated competency in this skill. The nurse should ensure that the AP is familiar with the facility's policies and procedures regarding catheter care and can perform the task safely and effectively.
Demonstrating how to use an incentive spirometer requires specialized knowledge and the ability to provide clear instructions. It is typically within the scope of practice of licensed healthcare professionals, such as nurses or respiratory therapists, who have the necessary expertise to properly educate and guide patients in using an incentive spirometer. This task should not be delegated to an AP.
Measuring and assessing the depth of a pressure injury requires clinical judgment and accurate evaluation, which falls within the scope of practice of a licensed nurse. It involves understanding wound assessment, proper technique for measuring depth, and interpreting the findings. This task should be performed by the nurse rather than an AP.
Changing the appliance on a new colostomy involves skills such as assessing the stoma, selecting the appropriate appliance, and ensuring proper application. This task requires specialized knowledge and training in stoma care, and it should be performed by a licensed nurse who has the expertise in managing ostomies. It should not be delegated to an AP.
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Related Questions
Correct Answer is B
Explanation
The nurse should include maintaining elbow restraints on the infant in the plan of care following cleft palate repair. This helps to prevent the infant from touching their surgical site and disrupting the healing process.
a) Allowing the infant to have soft foods may be appropriate, but it is not the highest priority. The infant's diet should be determined by the provider and based on the infant's individual needs.
c) Instructing the parents to feed the infant with a spoon may be appropriate, but it is not the highest priority. The infant's feeding method should be determined by the provider and based on the infant's individual needs.
d) Telling the parents to avoid brushing the infant's teeth for two weeks may be appropriate, but it is not the highest priority. The infant's oral care should be determined by the provider and based on the infant's individual needs.
Correct Answer is B
Explanation
b. FLACC Scale.
Explanation: The FLACC (Face, Legs, Activity, Cry, Consolability) Scale is a pain assessment tool commonly used for infants and young children who are unable to self-report their pain. It assesses five categories of behavior: facial expression, leg movement, activity level, cry, and consolability. Each category is scored from 0 to 2 or 0 to 3, depending on the specific scale used. The scores are then totaled to provide an overall pain assessment.
The FACES Scale, also known as the Wong-Baker FACES Pain Rating Scale, is a tool commonly used for children who can understand and self-report their pain. It consists of a series of faces with different expressions representing varying degrees of pain.
The Color tool is not a recognized pain rating tool. It may refer to an assessment of skin color, which can be used to assess oxygenation or circulation but not specifically for pain.
The Numeric scale is a pain rating tool that involves asking the individual to rate their pain on a scale from 0 to 10, with 0 being no pain and 10 being the worst pain imaginable. However, this scale may not be suitable for a 3-month-old infant who is unable to comprehend numbers or communicate effectively.
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