A nurse asks an assistive personnel (AP) to take a specimen to the laboratory, and the AP refuses. Which of the following actions should the nurse take?

The correct answers are Choices A, D, and E.

Choice A rationale:Providing postmortem care to a client who has just passed away is a task that can be delegated to assistive personnel (AP). Postmortem care involves cleaning and preparing the body after death and is not a task that requires the specialized skills or judgement of a nurse. It is important to note that while the physical task of postmortem care can be delegated, the nurse is still responsible for providing emotional support and information to the family, coordinating with the morgue or funeral home, and completing any required documentation.

Choice B rationale:Instructing a client about the use of a spirometer is not a task that should be delegated to assistive personnel. Patient education requires assessment and evaluation of the patient’s understanding, which are nursing responsibilities. A spirometer is a medical device used to measure lung function and is often used after surgery to help prevent complications like pneumonia. Proper use of the spirometer is crucial to its effectiveness, so it is important that the instruction is clear and understood by the patient.

Choice C rationale:Suctioning a client’s newly inserted tracheostomy is not a task that should be delegated to assistive personnel. Tracheostomy care, especially suctioning, requires specialized skills and knowledge, as well as the ability to assess the patient’s respiratory status. Improper suctioning can cause trauma to the trachea, hypoxia, or infection. Therefore, this task should be performed by a nurse or other licensed healthcare professional.

Choice D rationale:Transferring a client to radiology for x-rays is a task that can be delegated to assistive personnel. This task involves physical assistance and does not require specialized nursing skills or judgement. However, the nurse should provide the AP with any necessary information about the patient’s condition, mobility, and any precautions that need to be taken during the transfer.

Choice E rationale:Performing a simple dressing change on a client’s arm is a task that can be delegated to assistive personnel. This task involves changing the bandages on a wound, which is a task that does not require specialized nursing skills or judgement. However, the nurse should ensure that the AP has been properly trained in dressing changes, understands the importance of infection control, and knows when to report any changes in the wound’s appearance.

The first action the nurse should take is to collect data on the client. This includes assessing the client's condition and vital signs to determine if they require immediate medical attention.
Option b may not be appropriate without first assessing the client's condition.
Option c may be necessary after collecting data on the client, but it should not be the first action taken.
Option d may also be necessary, but it should not be the first action taken.