The charge nurse in an emergency center is planning client care assignments for the staff. Which action may be safely delegated to the practical nurse (PN)?
Provide client with resources and discharge teaching
Educate the clients about prescribed dietary changes.
Establish blood pressure parameters for client monitoring
Reinforce diet teaching for discharge to home
The Correct Answer is D
Choice A Reason: This action requires assessment and evaluation skills, which are beyond the scope of practice of the PN. The nurse is responsible for providing client education and ensuring that the client understands the discharge instructions.
Choice B Reason: This action requires teaching and evaluation skills, which are beyond the scope of practice of the PN. The nurse is responsible for educating the clients about their prescribed dietary changes and assessing their learning needs and readiness.
Choice C Reason: This action requires critical thinking and decision-making skills, which are beyond the scope of practice of the PN. The nurse is responsible for establishing the blood pressure parameters for client monitoring and adjusting them as needed.
Choice D Reason: This action can be safely delegated to the PN, as it involves reinforcing previous teaching done by the nurse. The PN can review the diet information with the client and answer any questions they may have.
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Correct Answer is A
Explanation
Choice A Reason: This is the best action because it helps the client meet their nutritional needs and prevents further weight loss. The nurse should delegate tasks that are within the scope of practice of the UAP, such as feeding assistance.
Choice B Reason: This is not an appropriate action because it requires a nursing assessment and intervention. The nurse should determine if the client is at risk for aspiration and consult with a speech therapist or dietitian before modifying the client's diet.
Choice C Reason: This is not a relevant action because it does not address the nursing problem of altered nutrition. The nurse should monitor the client's respiratory status and oxygenation, but this is not a task that can be delegated to the UAP.
Choice D Reason: This is not a sufficient action because it does not ensure that the client will consume enough food. The nurse should educate the client on the importance of high-protein foods, but this is not a task that can be delegated to the UAP.
Correct Answer is A
Explanation
Choice A Reason: This is the correct answer because the nurse should immediately inform the healthcare provider of the medication error and the client's condition. The healthcare provider may order antidotes, such as protamine sulfate for heparin and vitamin K for warfarin, to reverse the anticoagulant effects and prevent bleeding complications.
Choice B Reason: Monitoring for signs of bleeding is important but not the priority action for the nurse because it does not address the cause of the problem or prevent further harm. The nurse should monitor the client's vital signs, hemoglobin, hematocrit, and urine output, as well as check for any signs of bleeding, such as bruising, petechiae,
hematuria, hematemesis, melena, or epistaxis.
Choice C Reason: Completing an adverse occurrence report is important but not the priority action for the nurse because it does not provide immediate intervention or treatment for the client. The nurse should complete an
adverse occurrence report after notifying the healthcare provider and implementing appropriate actions. The report should include the details of the error, such as the time, dose, route, and name of the medications involved, as well as the client's response and outcome.
Choice D Reason: Obtaining blood for coagulation studies is important but not the priority action for the nurse because it does not provide immediate intervention or treatment for the client. The nurse should obtain blood
samples for coagulation studies, such as prothrombin time (PT), international normalized ratio (INR), and activated partial thromboplastin time (aPTT), after notifying the healthcare provider and following their orders. The results of these tests can help determine the extent of anticoagulation and guide further therapy.
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