A nurse on a medical-surgical unit is delegating client care. Which of the following tasks should the nurse delegate to an assistive personnel?

Suctioning a client's long-term tracheostomy

Using a pain rating scale to monitor a client's pain level

Performing a dressing change on a client's peripherally inserted central catheter

Instructing a client on self-administration of a tap water enema

Answer and Explanation

The Correct Answer is B

The correct answer is: B.

Choice A reason:

Suctioning a client's long-term tracheostomy is a complex procedure that involves sterile technique and assessment skills that are beyond the scope of assistive personnel's practice. It requires clinical judgment and the ability to respond to complications, which are responsibilities typically reserved for licensed nursing staff.

Choice B reason:

Using a pain rating scale to monitor a client's pain level is a task that can be delegated to assistive personnel. It involves asking the client to rate their pain on a scale, which does not require clinical judgment or advanced skills. The assistive personnel can then report the pain level to the nurse, who will make decisions regarding pain management.

Choice C reason:

Performing a dressing change on a client's peripherally inserted central catheter (PICC) is not within the scope of assistive personnel. This task requires aseptic technique and knowledge of PICC line management to prevent infection and other complications, which are typically the responsibility of the registered nurse or licensed practical nurse.

Choice D reason:

Instructing a client on self-administration of a tap water enema involves teaching and assessment to ensure the client understands and can perform the procedure safely. This is a task that requires licensed nursing knowledge and skills to educate the client and evaluate their competency.

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Correct Answer is B

Explanation

Choice A reason: A client who has a raised red skin rash on his arms, neck, and face may have an allergic reaction or a skin infection, which are not life-threatening conditions. The nurse should monitor the client for signs of anaphylaxis or systemic infection, but this client is not the highest priority.

Choice B reason: A client who has active bleeding from a puncture wound of the left groin area is the highest priority because they are at risk of hemorrhage and shock. The nurse should apply direct pressure to the wound, elevate the affected leg, and monitor the client's vital signs and hemoglobin level.

Choice C reason: A client who reports shortness of breath and left neck and shoulder pain may have a cardiac or pulmonary problem, such as angina, myocardial infarction, or pulmonary embolism, which are serious conditions. The nurse should obtain an electrocardiogram, administer oxygen, and prepare for further diagnostic tests and interventions, but this client is not the highest priority.

Choice D reason: A client who reports right-sided flank pain and is diaphoretic may have a renal or urinary problem, such as kidney stones, pyelonephritis, or renal colic, which are painful but not life-threatening conditions. The nurse should administer analgesics, encourage fluid intake, and collect a urine sample, but this client is not the highest priority.

A. Morphine sulfate 10.0 mg every 4 hours IV prn for pain B. MSO4 10 mg IVP q4h prn for pain C. Morphine sulfate 10 mg IV q4h prn for pain D. MS 10 mg IV every 4 prn for pain

Correct Answer is C

Explanation

Choice A reason: This is not the correct way to transcribe a verbal prescription. The nurse should not use decimals or trailing zeros when writing doses, as they can be misread or mistaken for larger doses. For example, 10.0 mg could be read as 100 mg.

Choice B reason: This is not the correct way to transcribe a verbal prescription. The nurse should not use abbreviations that are not approved by the facility or the Joint Commission, as they can be confusing or ambiguous. For example, MSO4 could be confused with magnesium sulfate (MgSO4).

Choice C reason: This is the correct way to transcribe a verbal prescription. The nurse should write the full name of the drug, the dose, the route, the frequency, and the indication for use. The nurse should also use standard abbreviations that are clear and unambiguous. For example, IV means intravenous, q4h means every 4 hours, and prn means as needed.

Choice D reason: This is not the correct way to transcribe a verbal prescription. The nurse should not use abbreviations that are not approved by the facility or the Joint Commission, as they can be confusing or ambiguous. For example, MS could be confused with morphine sulfate or magnesium sulfate. The nurse should also use standard abbreviations for the route and frequency, not words like every or prn.

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A nurse on a medical-surgical unit is delegating client care. Which of the following tasks should the nurse delegate to an assistive personnel?

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