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. Leukorrhea is correct. Leukorrhea, a normal increase in vaginal discharge, is a common discomfort during the first trimester of pregnancy. It is typically white or clear and odorless, and is caused by hormonal changes.

B. Burning during urination is incorrect. Burning during urination is not a normal discomfort of pregnancy and could indicate a urinary tract infection (UTI), which requires further evaluation and treatment.

C. Swelling of the face is incorrect. Swelling, especially of the face, is not typical during the first trimester and could be a sign of a more serious condition, such as preeclampsia, and should be investigated further.

D. Diarrhea is incorrect. While gastrointestinal changes can occur during pregnancy, diarrhea is not typically a common discomfort of the first trimester. Constipation, on the other hand, is more common due to hormonal changes that slow down bowel motility.

A. Respiratory rate 16/min B. Blood pressure 110/70 mm Hg C. 400 mL of drainage in the collection chamber within 4 hr D. Fluctuation in the water seal chamber with respiration

Correct Answer is C

Explanation

A. Respiratory rate 16/min is a normal finding. A respiratory rate of 16/min is within the expected range for adults, so it does not indicate a problem that requires immediate attention.

B. Blood pressure 110/70 mm Hg is within the normal range for blood pressure. This is an acceptable finding and does not require reporting to the charge nurse.

C. 400 mL of drainage in the collection chamber within 4 hr should be reported to the charge nurse. This is an excessive amount of drainage for a client with a chest tube. After the first few hours post-surgery, the drainage should decrease. Large amounts of drainage may indicate bleeding, and it is important to notify the charge nurse immediately to assess the situation further.

D. Fluctuation in the water seal chamber with respiration is a normal finding. It is expected for the water seal chamber to fluctuate with the client’s respirations, indicating that the chest tube is functioning properly and the system is not obstructed.

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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

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