A charge nurse is delegating tasks for a group of clients on a medical surgical unit. Which of the following tasks should the nurse delegate to the assistive personnel?
Educate a client about the purpose of a sputum specimen.
Perform irrigation of an indwelling urinary catheter.
Administer liquid aspirin to a client who is crying.
Provide a bed bath for a client who requires isolation precautions.
The Correct Answer is D
A. Educate a client about the purpose of a sputum specimen: Client education requires nursing knowledge and judgment to explain procedures, answer questions, and evaluate understanding. This cannot be delegated to assistive personnel.
B. Perform irrigation of an indwelling urinary catheter: Catheter irrigation is a sterile invasive procedure that requires nursing skill to prevent infection and complications. It falls outside the scope of assistive personnel.
C. Administer liquid aspirin to a client who is crying: Medication administration involves assessment, calculation, and monitoring for adverse effects, which are responsibilities of a licensed nurse. Assistive personnel cannot administer medications.
D. Provide a bed bath for a client who requires isolation precautions: Assisting with hygiene is within the scope of assistive personnel. They can safely provide a bed bath while following isolation protocols under the supervision of the nurse.
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Related Questions
Correct Answer is C
Explanation
Rationale:
A. "This medication can cause back pain.": Back pain is not a common or expected adverse effect of warfarin. Teaching should focus on bleeding risks and precautions rather than unrelated symptoms.
B. "Avoid taking this medication with milk products.": Milk does not significantly affect warfarin absorption. The main dietary consideration is maintaining consistent vitamin K intake, as large fluctuations can alter anticoagulation.
C. "Use an electric razor when shaving while taking this medication.": Warfarin increases the risk of bleeding and bruising. Using an electric razor reduces the chance of cuts, promoting safety during routine grooming.
D. "Avoid prolonged exposure to sunlight while taking this medication.": Sun exposure is not contraindicated with warfarin; there is no significant interaction between warfarin and UV light.
Correct Answer is D
Explanation
Rationale:
A. Provide a tracheostomy tray at the bedside: A tracheostomy tray is not routinely required for seizure precautions, as airway obstruction in seizures is usually managed through positioning and suctioning.
B. Place the client in supine position: The supine position can increase the risk of airway obstruction and aspiration after a seizure. A side-lying position is preferred to help maintain an open airway and promote drainage of secretions.
C. Place a plastic tongue depressor at the client's bedside: Placing any object in a client’s mouth during or after a seizure can cause injury to the teeth, gums, or airway. Modern seizure precautions avoid using tongue blades or depressors entirely.
D. Insert an IV saline lock: Having IV access readily available allows rapid administration of emergency medications such as benzodiazepines if the client experiences another seizure. This intervention supports prompt treatment and stabilization.
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