A nurse is caring for a client who has just returned to the unit from the PACU, Which of the following tasks should the nurse assign to the assistive personnel?
Assist the nurse to transfer the client to the bed.
Check the client's dressing for bleeding.
Obtain the client's vital signs.
Ask the client if he requires pain medication.
The Correct Answer is A
Rationale:
A. Assisting the nurse to transfer the client to the bed is an appropriate task to delegate to assistive personnel (AP). It is considered basic care and does not require nursing judgment, making it safe and within the AP’s scope of practice. Safe patient handling protocols should be followed to prevent injury.
B. Checking the client’s dressing for bleeding requires assessment and clinical judgment, which are nursing responsibilities. The AP cannot accurately assess postoperative complications or interpret clinical findings.
C. Obtaining vital signs may sometimes be delegated to APs, but postoperative clients returning from the PACU are unstable, and the nurse must assess vital signs and interpret the data immediately to detect complications. Therefore, this task should remain with the nurse.
D. Asking the client if they require pain medication involves assessment of pain and clinical judgment regarding medication administration. Pain management is a nursing responsibility and cannot be delegated to APs.
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Related Questions
Correct Answer is A
Explanation
Rationale:
A. Administering a hepatitis B vaccine is within the scope of practice for an LPN. LPNs are trained and licensed to administer routine injections and vaccines, monitor for immediate adverse reactions, and document administration. This task does not require the higher-level assessment skills of an RN, making it appropriate for delegation. Administering immunizations to newborns is a standard, routine intervention that aligns with an LPN’s responsibilities under RN supervision.
B. Conducting a newborn hearing screening involves specialized assessment techniques and interpretation of results. This task is typically performed by a trained RN, audiologist, or certified hearing screener, as it requires advanced assessment skills and understanding of neonatal hearing protocols. Assigning this to an LPN is inappropriate.
C. Performing a New Ballard assessment (used to determine gestational age) requires advanced neonatal assessment skills, including observation of neuromuscular and physical maturity signs. This is a competency reserved for RNs or clinicians trained in neonatal assessments and is beyond the typical LPN scope of practice.
D. Obtaining vital signs is a basic nursing task that can be delegated to an assistive personnel (AP). APs are competent to measure and record temperature, heart rate, respiratory rate, and blood pressure, freeing RNs and LPNs to perform tasks that require more skill and clinical judgment.
Correct Answer is B
Explanation
Rationale:
A. A client experiencing chest pain with radiation to the arm is at high risk for a life-threatening condition such as myocardial infarction. This client would be tagged red (immediate) because they require urgent intervention to prevent death.
B. A client with a deep laceration to the leg who is stable and not experiencing life-threatening bleeding would be assigned a yellow tag (delayed). Yellow-tagged patients have serious injuries that require medical attention but can wait for a short period without immediate threat to life. This classification allows resources to be prioritized for patients who are in more critical condition.
C. A client with a large bruise to the shoulder with no other complications is considered a green tag (minor, “walking wounded”). This client’s injuries are not life-threatening and can safely wait for treatment.
D. A client who is unable to breathe without manual ventilation requires immediate life-saving intervention and would be tagged red (immediate) due to the high risk of death without urgent care.
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