A nurse checks with assistive personnel on the unit throughout the shift to determine if they are completing tasks. The nurse is demonstrating which of the following rights of delegation?

Right circumstances

Right communication

Right supervision

Right person

Answer and Explanation

The Correct Answer is C

A. Right Circumstances:
This involves ensuring that the tasks being delegated are appropriate for the circumstances and consistent with the plan of care. The nurse should consider factors such as the client's condition, the complexity of the task, and the stability of the client's health status.

B. Right Communication:
Effective communication is crucial in delegation. This includes clear and concise instructions, expectations, and a feedback loop. The nurse should ensure that communication is understood and acknowledged by both parties involved in the delegation.

C. Right Supervision:
Right Supervision involves providing guidance, direction, and feedback to those to whom tasks have been delegated. The nurse is responsible for overseeing and ensuring that the tasks are performed appropriately, meeting the required standards of care. This includes ongoing monitoring and assessment of delegated tasks.

D. Right Person:
The right person involves selecting the appropriate individual for the task based on their competence, knowledge, and skills. The nurse must assess the competency of the person being delegated to and ensure that they have the necessary qualifications to perform the assigned task

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Correct Answer is B

Explanation

A. A client who has a prescription for insulin, and his premeal capillary blood glucose was 110 mg/dL, and his post-meal capillary blood glucose is now 160 mg/dL:
While changes in blood glucose levels are important to monitor, the described change is not as significant as a sudden drop in blood pressure. The blood glucose levels in this scenario are still within a reasonable range.

B. A client whose blood pressure at 0800 was 138/86 mm Hg, and at 1200 is 106/60 mm Hg:
This is the priority client. The significant drop in blood pressure raises concerns about hypovolemia or circulatory issues, which require immediate attention to prevent complications such as inadequate organ perfusion.

C. A client who reports pain as 4 on a scale of 1 to 10 at 0800 and now reports pain as 6:
Pain management is important, but the change in pain intensity from 4 to 6, while indicating an increase, may not be as urgent as addressing a significant drop in blood pressure. Pain assessment and management can be addressed after stabilizing the client with the acute change.

D. A client whose wound drainage at 0800 was sanguineous, and now it is serosanguineous:
Changes in wound drainage color can be important for assessing the healing process, but a shift from sanguineous to serosanguineous is generally within the expected progression of wound healing. It may not require immediate intervention as compared to a significant drop in blood pressure.

A. Elevate the client’s head of bed B. Assess the client’s away. C. Prepare the client for intubation D. Suction the client’s mouth

Correct Answer is B

Explanation

A. Elevate the client’s head of bed:
Elevating the head of the bed is a good practice for patients on mechanical ventilation as it helps prevent complications such as aspiration. However, in the scenario where the client has pulled out the endotracheal tube, the immediate concern is assessing the airway and ensuring adequate oxygenation and ventilation. Elevating the head of the bed can be done later as needed.

B. Assess the client’s airway:
This is the correct and priority action. The nurse should assess the client's airway first to determine the extent of the situation. This involves checking for signs of airway obstruction, respiratory distress, or inadequate oxygenation. The assessment guides subsequent interventions.

C. Prepare the client for intubation:
While preparing for intubation may be necessary if the endotracheal tube is completely displaced, assessing the airway comes first. The nurse needs to gather information about the client's current condition before deciding on the appropriate course of action.

D. Suction the client’s mouth:
Suctioning may be necessary, especially if there are secretions or other obstructions in the mouth or airway. However, it should come after the initial assessment of the airway. If the client's airway is clear, suctioning may not be the immediate priority.

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A nurse checks with assistive personnel on the unit throughout the shift to determine if they are completing tasks. The nurse is demonstrating which of the following rights of delegation?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for four clients who are postoperative from surgery 24 hr ago. At 1200 the nurse assesses the clients. Which of the clients is the nurse’s priority?

Correct Answer is B

Explanation

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Correct Answer is B

Explanation

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