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:

The age of the client might impact the care plan, but it doesn't directly relate to the cost effectiveness of care. Older patients might have different health considerations, but the length of their stay and the services they require play a more significant role in cost evaluation.

Choice B rationale:

While the availability of community support groups can be beneficial for the client's overall well-being and recovery, it doesn't directly contribute to evaluating the cost effectiveness of care. Community support groups are more about psychosocial support than cost.

Choice C rationale:

This is the correct choice. The length of the client's stay directly affects the cost of care. Longer stays often involve more resources, medications, treatments, and staff time, leading to higher costs. Shorter and more efficient stays are generally more cost-effective.

Choice D rationale:

The type of insurance the client carries is relevant to the client's financial responsibility for their care, but it doesn't assist in evaluating the overall cost effectiveness of care. The insurance type might affect reimbursement rates, but it doesn't provide a comprehensive picture of cost efficiency.

A. A nurse is photocopying their assigned client's diagnostic test results. B. An assistive personnel (AP) documents a client's vital signs on the client's paper-based graphic record. C. The unit secretary faxes a client's laboratory results to the provider. D. An RN stays with a client who is reading the medical records that were requested.

Correct Answer is A

Explanation

The correct answer is choice A: A nurse is photocopying their assigned client's diagnostic test results.

Choice A rationale: The charge nurse should intervene because photocopying a client's diagnostic test results can pose a potential breach of confidentiality and privacy. Unless there is a specific and authorized reason, personal health information should not be copied or removed from the client's medical record.

Choice B rationale: An assistive personnel (AP) documenting a client's vital signs on the client's paper-based graphic record is a routine task and does not require intervention by the charge nurse.

Choice C rationale: The unit secretary faxing a client's laboratory results to the provider is a standard practice for sharing necessary health information with the care team. No intervention is required.

Choice D rationale: An RN staying with a client who is reading their requested medical records is appropriate. Clients have the right to access their own medical records, and the nurse's presence can help address any questions or concerns the client might have while reviewing their records.

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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)?

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