A charge nurse is making staff assignments on a medical-surgical unit. Which of the following tasks should the nurse plan to delegate to an assistive personnel?

Pouching a client's ostomy bag for a new colostomy

Performing nasal hygiene for a client who has an NG tube

Measuring oxygen saturation for a client who has dyspnea

Inserting a rectal suppository for a client who is vomiting

Answer and Explanation

The Correct Answer is B

A.   Pouching a client's ostomy bag for a new colostomy requires specialized training and should typically be performed by a nurse.
B.   Performing nasal hygiene for a client with an NG tube involves basic hygiene tasks that can be safely delegated to an assistive personnel after proper training and supervision.
C.   Measuring oxygen saturation for a client who has dyspnea requires a basic skill that can be delegated to an assistive personnel.
D.   Inserting a rectal suppository for a vomiting client involves a nursing task that should be performed by a nurse due to the client's condition and the nature of the task.

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Correct Answer is B

Explanation

A. Keeping all four side rails up on beds can increase the risk of entrapment or injury and isn't recommended as a fall prevention strategy.
B. Instituting regular rounds during the day to offer toileting helps prevent falls related to residents attempting to get to the bathroom independently.
C. Accompanying older residents during ambulation is helpful but might not be feasible at all times and for all residents.
D. Using vest restraints can lead to physical and psychological complications and is not recommended due to ethical and safety concerns.

A. Ask the client if she would like a sedative to help her relax. B. Inform the client that she cannot leave without a discharge prescription from the provider. C. Assign a security officer to the client's room until the provider can speak with the client. D. Have the client sign the Against Medical Advice form.

Correct Answer is B

Explanation

A. Offering a sedative might not address the situation appropriately; the client's decision to leave needs to be managed through proper channels.
B. Informing the client about the discharge process and the requirement of a discharge prescription from the provider is appropriate and educates the client on the necessary steps.
C. Assigning a security officer might not be necessary unless there are safety concerns or imminent risks.
D. Having the client sign the Against Medical Advice (AMA) form might be necessary if the client insists on leaving against medical advice, but explaining the proper discharge process should be attempted first.

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A charge nurse is making staff assignments on a medical-surgical unit. Which of the following tasks should the nurse plan to delegate to an assistive personnel?

Nursing Test Bank

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