Which of the following instructions provided by a nurse reflects effective communication regarding delegation of a task to an assistive personnel (AP)?

"Take vital signs every 2 hours for the client who had a cholecystectomy in room 6122.”

"Check the urinary output at 11:00 for John Doe and report it to me immediately.”

"Report to me if the chest tube drainage is excessive for Jane Doe in room 2438.”

"Please notify me of any clients whose vital signs or blood glucose levels are significant.”

Answer and Explanation

The Correct Answer is B

The answer is b. "Check the urinary output at 11:00 for John Doe and report it to me immediately.”

This instruction follows the five rights of delegation by including the requirements for right direction/communication: the data to collect, client-specific information, a timeline for data collection, and the expectation for communicating the findings back to the nurse.

a. "Take vital signs every 2 hours for the client who had a cholecystectomy in room 6122.” is wrong because it does not specify which client to monitor. The AP should know the client’s name and room number for identification and safety purposes.

c. "Report to me if the chest tube drainage is excessive for Jane Doe in room 2438.” is wrong because it does not define what constitutes excessive drainage. The nurse should provide clear and measurable criteria for the AP to follow.

d. "Please notify me of any clients whose vital signs or blood glucose levels are significant.” is wrong because it is vague and does not indicate which clients to check, how often to check them, or what values are significant. The nurse should provide specific and individualized instructions for each client

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Correct Answer is C

Explanation

Choice A rationale:

Notify the charge nurse of the client's request for transfer. This action might be taken eventually, but it is not the first step. The nurse should directly address the client's concerns before escalating the situation to the charge nurse.

Choice B rationale:

Assure the client that their concern has been shared with the staff. Tell the client that future calls will be answered in a timely manner. While it's important to reassure the client, promising timely responses to calls before understanding their expectations might not effectively address the underlying issue. It's better to communicate openly with the client first.

Choice C rationale:

Ask the client to verbalize their expectations. This is the correct choice. By asking the client to express their expectations, the nurse can gather crucial information about the client's concerns and needs. This allows the nurse to address the specific issues that led to the client's dissatisfaction and work toward a resolution that aligns with the client's preferences.

A. Auscultate the client's bowel sounds. B. Measure the client's temperature. C. Check the client's urine specific gravity. D. Obtain the client's serum potassium level.

Correct Answer is D

Explanation

The correct answer is choice D.

Choice A rationale:

“Auscultate the client’s bowel sounds.” While auscultating bowel sounds can provide information about the client’s gastrointestinal function, it is not the priority assessment for a client who has been vomiting and experiencing diarrhea for the past 6 hours.

Choice B rationale:

“Measure the client’s temperature.” Measuring the client’s temperature can help identify if the client has an infection, which could be causing the vomiting and diarrhea. However, it is not the priority assessment in this situation.

Choice C rationale:

“Check the client’s urine specific gravity.” Checking the client’s urine specific gravity can provide information about the client’s hydration status. However, it is not the priority assessment for a client who has been vomiting and experiencing diarrhea for the past 6 hours.

Choice D rationale:

“Obtain the client’s serum potassium level.” This is the correct answer. Prolonged vomiting and diarrhea can lead to significant loss of electrolytes, including potassium. A low potassium level (hypokalemia) can have serious effects, including cardiac arrhythmias. Therefore, obtaining the client’s serum potassium level is the priority assessment.

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Which of the following instructions provided by a nurse reflects effective communication regarding delegation of a task to an assistive personnel (AP)?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is D

Explanation

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