A nurse delegates a task to an assistive personnel (AP) and the AP refuses to complete the assigned task. Which of the following actions should the nurse take?

Assign the task to another AP.

Report the AP to the risk manager.

Discuss the AP's concerns about performing the task.

Perform the task on behalf of the AP.

Answer and Explanation

The Correct Answer is C

A. "Assign the task to another AP" is not the best first response. The nurse should first understand why the AP is refusing the task and address any concerns before reassigning the task.

B. "Report the AP to the risk manager" is premature. The nurse should first attempt to understand the AP’s reasons for refusal and resolve any concerns directly. Reporting should only occur if the issue persists and cannot be resolved.

C. "Discuss the AP's concerns about performing the task" is correct. The nurse should open a dialogue with the AP to understand why they are refusing the task. This allows the nurse to assess if the refusal is due to lack of knowledge, skill, or comfort, and then provide the necessary support, guidance, or training.

D. "Perform the task on behalf of the AP" is not ideal. The nurse should not assume the task but rather address the issue with the AP. The nurse should only intervene if the task needs to be completed urgently, but the first step should be to explore the reasons for refusal.

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Correct Answer is A

Explanation

A. Injecting 15 units of air into the regular insulin vial is correct. When drawing up two types of insulin, the nurse should first inject air into the NPH (cloudy) insulin vial without withdrawing the medication. Then, the nurse should inject air into the regular (clear) insulin vial before withdrawing the regular insulin. This prevents contamination and maintains proper insulin mixing procedures.

B. Placing the cap over the needle is incorrect. Once insulin preparation has started, recapping the needle is unnecessary and increases the risk of contamination or needlestick injury.

C. Verifying the dosage with another nurse is incorrect at this stage. Dosage verification should be done after the correct amounts of insulin are drawn into the syringe, not before.

D. Withdrawing 10 units of NPH insulin is incorrect. The nurse should first withdraw the regular (clear) insulin before drawing up the NPH (cloudy) insulin to avoid contaminating the regular insulin with the longer-acting insulin.

A. The client's heart rate has increased to 110/min. B. The client grimaces when changing positions. C. The client reports pain as 7 on a scale of 0 to 10. D. The client demonstrates a decreased attention span.

Correct Answer is C

Explanation

A. The client's heart rate has increased to 110/min is incorrect. While an increased heart rate can indicate pain, it can also be caused by other factors such as anxiety, dehydration, or fever. Heart rate alone is not the most specific or reliable indicator for the need for analgesia.

B. The client grimaces when changing positions is a possible sign of discomfort, but the level of pain cannot be accurately assessed from facial expressions alone. This may suggest mild to moderate pain but does not provide a clear numerical indication of the client's pain level.

C. The client reports pain as 7 on a scale of 0 to 10 is correct. The pain scale is a more direct and reliable measure of the client's pain experience. A rating of 7 indicates moderate to severe pain, which justifies the need for analgesic intervention.

D. The client demonstrates a decreased attention span could be related to pain or discomfort, but it may also result from other causes, such as fatigue, emotional stress, or medication side effects. This is not as definitive as a self-reported pain level.

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A nurse delegates a task to an assistive personnel (AP) and the AP refuses to complete the assigned task. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has a prescription for NPH insulin 10 units and regular insulin 15 units subcutaneously. After injecting 10 units of air into the NPH insulin vial, which of the following actions should the nurse take next?

Correct Answer is A

Explanation

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Correct Answer is C

Explanation

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