A nurse is assisting with planning care for a group of clients. Which of the following tasks should the nurse delegate to an assistive personnel?
Changing the dressing on a client's IV site
Suctioning a client's new tracheostomy
Evaluating a client's risk for developing pressure injuries
Administering a large-volume enema to a client
The Correct Answer is D
A. Changing the dressing on a client's IV site: This is a sterile procedure and requires the nurse’s clinical expertise. It cannot be delegated to assistive personnel (AP).
B. Suctioning a client's new tracheostomy: Suctioning a tracheostomy, especially a new one, is a sterile procedure requiring clinical judgment and skill, which is beyond the scope of assistive personnel.
C. Evaluating a client's risk for developing pressure injuries: This is an assessment task that requires clinical judgment and critical thinking. It falls under the nurse’s scope of practice and should not be delegated to AP.
D. Administering a large-volume enema to a client: Assisting with or administering an enema is a task that can be delegated to assistive personnel, as it is within their scope of practice, provided the client is stable and the procedure does not require complex judgment.
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Related Questions
Correct Answer is C
Explanation
A. Turn the newborn's head quickly to one side while they are sleeping: This action does not elicit the Moro reflex. The Moro reflex is a response to a sudden loss of support, not a head-turning motion.
B. Place a finger in the newborn's palm: This action would elicit the palmar grasp reflex, not the Moro reflex.
C. Clap hands after laying the newborn on a flat surface: The Moro reflex is triggered by a sudden, loud noise or movement, such as clapping hands. This response causes the newborn to extend and then quickly flex the arms, a characteristic sign of the reflex.
D. Hold the newborn upright with one foot touching the crib surface: This action is not related to the Moro reflex. The stepping reflex is elicited by holding the newborn upright with their feet touching a surface, not the Moro reflex.
Correct Answer is A
Explanation
A. This response respects the client's autonomy and right to make decisions about their own healthcare. It acknowledges the client's right to refuse treatment, even if it is recommended by healthcare providers.
B. While it is important to communicate the client's wishes to the healthcare provider, the nurse should not threaten to report the client's decision without their consent. This could undermine trust between the nurse and the client.
C. While it is true that refusing treatment may have medical consequences, this statement may come across as judgmental or coercive. The nurse should provide information about the potential consequences of refusing treatment in a supportive and non-coercive manner.
D. Suggesting that the client consult with a clergyperson before making a treatment decision is not necessarily relevant to the client's medical decision-making process. It may also imply that the decision should be based on religious beliefs rather than personal values and preferences.
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