A nurse is assigning care for four clients. Which of the following tasks should the nurse plan to delegate to an assistive personnel (AP)?

Instruct a client how to take their blood pressure.

Administer subcutaneous medications to a client.

Determine a client's intake and output.

Provide a status update to a client's family member.

Answer and Explanation

The Correct Answer is C

The correct answer is Choice C.

Choice A rationale:

Instructing a client on how to take their blood pressure is a task that involves providing education to the client on a non-invasive procedure that they can perform independently. However, this task requires a certain level of knowledge and understanding that an assistive personnel (AP) may not possess. Therefore, it is not the best task to delegate to an AP.

Choice B rationale:

Administering subcutaneous medications to a client is a task that requires a high level of skill and knowledge. It involves understanding the medication, its side effects, and the correct administration technique. This is a task that should be performed by a nurse or a healthcare professional with the appropriate training and licensure. Delegating this task to an AP could potentially put the client’s health at risk.

Choice C rationale:

Determining a client’s intake and output is a task that can be delegated to an AP. This task does not require the use of the nursing process and is within the range of function of an AP. It involves measuring and recording the amount of fluid a client consumes and excretes, which is a task that an AP is capable of performing.

Choice D rationale:

Providing a status update to a client’s family member is a task that requires a high level of discretion and understanding of the client’s condition. It involves communicating sensitive information about the client’s health status, which should be done by a nurse or a healthcare professional with the appropriate training and licensure. Delegating this task to an AP could potentially lead to miscommunication or a breach of the client’s privacy.

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Correct Answer is C

Explanation

The correct answer is C.

Choice A: Take extra wheelchairs to the emergency department While having extra wheelchairs available can be helpful in a disaster situation, it is not the primary responsibility of the PACU charge nurse. The logistics of equipment distribution would typically be managed by a different team or department.

Choice B: Send PACU assistive personnel to assist with triage Triage is a critical part of disaster response, but it is typically performed by trained emergency department personnel or those with specific training in disaster triage. PACU personnel should focus on their area of expertise, which is post-anesthesia care.

Choice C: Identify stable clients for transfer to a surgical unit This is the correct action. By identifying stable clients for transfer, the PACU charge nurse can free up space for incoming patients who may require immediate post-operative care. This action helps to ensure that the PACU is ready to receive patients who are likely to come from the emergency department after immediate lifesaving interventions.

Choice D: Report to the command center for further instructions While communication with the command center is important in a disaster situation, the PACU charge nurse’s primary responsibility is to manage the care environment and patient flow within their specific unit. Other teams or personnel would likely handle tasks like reporting to the command center.

A. The child has red fissures at the corners of the mouth. B. The child has several small bruises on both legs. C. The child sleeps for about 13 hours each night. D. The child is not regularly attending school.

Correct Answer is B

Explanation

Choice A rationale:

The child having red fissures at the corners of the mouth is not the priority finding. While this could indicate a nutritional deficiency, such as vitamin B2 (riboflavin) deficiency, the presence of bruises on the child's legs raises more immediate concerns related to potential physical abuse or safety issues.

Choice B rationale:

The child having several small bruises on both legs is the priority finding. Bruising on a school-age child could indicate physical abuse or an unsafe living environment. Ensuring the child's safety and well-being takes precedence over other findings. Assessing the nature, pattern, and explanation for the bruises is crucial.

Choice C rationale:

The child sleeping for about 13 hours each night is not the priority finding in this scenario. While sleep patterns are important, the potential for physical abuse and safety concerns associated with the bruises takes precedence.

Choice D rationale:

The child not regularly attending school is a concern, but it is not the priority finding when compared to the possibility of physical abuse indicated by the bruises. Both issues need to be addressed, but ensuring the child's immediate safety is the primary focus.

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A nurse is assigning care for four clients. Which of the following tasks should the nurse plan to delegate to an assistive personnel (AP)?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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