A nurse on a medical-surgical unit is delegating client care. Which of the following tasks should the nurse delegate to an assistive personnel?
Using a pain rating scale to monitor a client's pain level
Instructing a client on self-administration of a tap water enema
Performing a dressing change on a client's peripherally inserted central catheter
Suctioning a client's long-term tracheostomy
The Correct Answer is A
Choice A reason: Using a pain rating scale to monitor a client's pain level is a task that the nurse can delegate to an assistive personnel, as it does not require clinical judgment or specialized skills. The assistive personnel can report the pain score to the nurse, who can then adjust the pain management plan accordingly.
Choice B reason: Instructing a client on self-administration of a tap water enema is a task that the nurse cannot delegate to an assistive personnel, as it requires teaching and evaluation skills. The nurse should instruct the client on the procedure, the rationale, and the expected outcomes, and assess the client's understanding and ability to perform the task.
Choice C reason: Performing a dressing change on a client's peripherally inserted central catheter is a task that the nurse cannot delegate to an assistive personnel, as it requires sterile technique and infection control skills. The nurse should perform the dressing change according to the facility protocol, and monitor the site for any signs of complications.
Choice D reason: Suctioning a client's long-term tracheostomy is a task that the nurse cannot delegate to an assistive personnel, as it requires advanced airway management skills. The nurse should suction the client's tracheostomy as needed, and observe the client for any signs of respiratory distress.
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Related Questions
Correct Answer is B
Explanation
Choice A reason: A nurse refusing to actively participate during an elective abortion procedure scheduled for their client is not a behavior that indicates a need for further education. The nurse has the right to conscientious objection, which means they can decline to perform or assist in a procedure that violates their moral or religious beliefs. The nurse should inform the charge nurse of their objection and request to be reassigned to another client.
Choice B reason: A nurse explaining to a client's family that a DNR order includes withholding comfort measures is a behavior that indicates a need for further education. The nurse is providing false and misleading information that can cause harm and distress to the client and the family. A DNR order only means that no cardiopulmonary resuscitation (CPR) or advanced cardiac life support (ACLS) will be initiated in the event of a cardiac or respiratory arrest. A DNR order does not affect the provision of other treatments, such as pain management, hydration, nutrition, oxygen, or emotional support.
Choice C reason: A nurse informing a confused client who wants to go home that they are going to stay at the facility until they are better is not a behavior that indicates a need for further education. The nurse is using therapeutic communication and providing reassurance to the client. The nurse is also respecting the client's autonomy and right to refuse treatment, as long as the client is competent and informed. The nurse should assess the client's mental status and decision-making capacity, and involve the client's family or surrogate decision-maker if needed.
Choice D reason: A nurse giving prescribed opioids to a client who has a terminal illness and respirations of 8/min is not a behavior that indicates a need for further education. The nurse is following the principle of beneficence, which means doing good and preventing harm to the client. The nurse is also following the principle of double effect, which means that an action that has both a good and a bad effect is morally permissible if the good effect outweighs the bad effect. The nurse is providing adequate pain relief to the client, even if it may hasten their death. The nurse should monitor the client's vital signs and level of consciousness, and adjust the opioid dose as prescribed.
Correct Answer is ["A","B","D"]
Explanation
Choice A reason: Documenting a client's refusal to take a prescribed medication is an example of client advocacy because it respects the client's right to make informed decisions about their health care. The nurse should also explain the risks and benefits of the medication and offer alternatives if possible.
Choice B reason: Providing written information to a client regarding palliative care is an example of client advocacy because it educates the client about their options and supports their quality of life. The nurse should also discuss the information with the client and answer any questions they may have.
Choice C reason: Implementing a client's plan of care based on nursing goals is not an example of client advocacy because it does not reflect the client's preferences and values. The nurse should collaborate with the client and the health care team to develop a plan of care that meets the client's needs and goals.
Choice D reason: Obtaining an interpreter for a client who speaks a different language than the nurse is an example of client advocacy because it facilitates effective communication and understanding between the nurse and the client. The nurse should use a professional interpreter or a translation device if available and avoid using family members or friends as interpreters.
Choice E reason: Initiating IV access on a client who has dementia while he is sleeping is not an example of client advocacy because it violates the client's autonomy and consent. The nurse should obtain informed consent from the client or their legal representative before performing any invasive procedure and explain the purpose and risks of the procedure.
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