A charge nurse is delegating tasks to nursing personnel on a 10-bed medical-surgical nursing unit. Which of the following assignments is an example of overdelegation?

Assigning the most efficient AP to perform glucometer monitoring for each client

Assigning two assistive personnel (AP) to ambulate all clients

Assigning a new graduate nurse to perform a wet-to-dry dressing change

Assigning the most competent RN to perform a central line dressing change

Answer and Explanation

The Correct Answer is C

A.   This task is generally appropriate for an assistive personnel (AP) if it is within their scope of practice and if proper training has been provided. Glucometer monitoring is a routine task that APs can often perform, assuming they are trained in using the glucometer and understanding the importance of accurate readings.

B.   Assigning two APs to ambulate all clients might be seen as overdelegation if the task requires more clinical judgment or if there are other tasks that need to be managed concurrently. Ambulating clients can sometimes be complex depending on their condition, and it’s essential to ensure that APs are appropriately trained and that the workload is balanced.
C.   Assigning a new graduate nurse to perform a wet-to-dry dressing change could be considered overdelegation if the task requires advanced skills and experience that the new graduate might not yet possess. Wet-to-dry dressing changes can be complex and require a certain level of expertise to ensure proper technique and patient safety.
D.   This task is typically appropriate for an RN with the necessary competencies and experience. A central line dressing change requires specific skills and knowledge, and delegating this task to the most competent RN ensures that it is performed correctly and safely. This is not considered overdelegation because it matches the task to the skill level of the RN.

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Correct Answer is D

Explanation

A. While a quiet environment is generally desirable for patients, a client in a manic phase often experiences increased energy and agitation. A quiet room might not adequately address their need for constant monitoring.
B. Seclusion should be used as a last resort and only in cases where the client poses an immediate danger to themselves or others. It is not appropriate for routine management of mania.
C. While it might seem helpful to pair patients with similar conditions, a manic patient can be disruptive to roommates, affecting their well-being and potentially escalating their own symptoms.
D. This option is the most appropriate. A private room provides necessary privacy and space, while proximity to the nursing station allows for close observation and rapid intervention if needed.

A. Client reports dull, aching pain in lower right calf. B. Client reports nausea following administration of pain medication. C. Client's oral temperature is 38.4° C (101.2° F). D. Client reports the rash on their back is itchy. E. Client has a vesicular rash on their upper back.

Correct Answer is ["A","B","D"]

Explanation

A. This is subjective data. The description of pain as "dull" and "aching" is based on the client's personal experience and cannot be measured directly by the nurse. Pain is a subjective symptom because it varies from person to person and is reported by the patient.
B. This is subjective data. Nausea is a feeling or sensation reported by the client and is based on their personal experience. The nurse relies on the client's report to assess this symptom, as it cannot be directly observed or measured.
C. This is objective data. The temperature reading is a measurable, quantifiable fact that can be directly observed and recorded by the nurse using a thermometer. It provides concrete evidence of the client's condition.
D. This is subjective data. Itchiness is a sensation reported by the client and is based on their personal experience. The nurse cannot measure itchiness directly; they rely on the client’s description to understand the symptom.
E. This is objective data. The presence of a vesicular rash is an observable finding that the nurse can see and document. It is a physical characteristic that can be directly assessed and recorded.

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A charge nurse is delegating tasks to nursing personnel on a 10-bed medical-surgical nursing unit. Which of the following assignments is an example of overdelegation?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is ["A","B","D"]

Explanation

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