A nurse is caring for a client who was admitted for treatment of a wound. Which of the following tasks should the nurse delegate to an assistive personnel?
Measure the size of the wound.
Collect a wound culture.
Ask the client to describe their pain level.
Transport the client for a wound debridement.
The Correct Answer is D
Rationale:
A. Measuring the size of a wound requires clinical judgment to accurately assess depth, length, width, and tissue characteristics. This task is within the registered nurse’s scope of practice and should not be delegated to an AP.
B. Collecting a wound culture is an invasive procedure that requires aseptic technique and clinical judgment to ensure accurate results and prevent infection. This task cannot be delegated to an AP.
C. Asking the client to describe their pain level involves assessment and documentation that requires nursing knowledge and judgment. The nurse must interpret the pain information and determine interventions.
D. Transporting the client for wound debridement is a non-invasive, routine task that does not require clinical judgment. An AP can safely assist the client in moving from the unit to the procedure area, ensuring mobility support and safety.
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Related Questions
Correct Answer is C
Explanation
Rationale:
A. Handling finances is addressed through a financial power of attorney, not an advance directive. Advance directives are focused on healthcare decisions, not financial matters.
B. A form for contacting a primary contact is not considered an advance directive. While it may be part of medical documentation, it does not specify healthcare decisions or treatment preferences.
C. Instructions regarding a durable power of attorney for healthcare are a key component of advance directives. This allows the client to designate a healthcare proxy or agent to make medical decisions on their behalf if they become unable to do so. Advance directives also often include living wills, which specify the client’s wishes regarding life-sustaining treatments.
D. Information about the disposition of the client’s body upon death is not part of an advance directive. This is typically addressed in a separate document, such as a funeral or burial plan.
Correct Answer is B
Explanation
Rationale:
A. Coordinating care is part of the nurse’s responsibilities, but it is not the primary role of advocacy. Advocacy focuses on supporting clients’ rights, preferences, and informed decision-making rather than assuming full responsibility for care coordination.
B. Empowering clients to make informed health care decisions is the essence of nursing advocacy. The nurse provides information, clarifies options, and supports the client in expressing their preferences and making decisions that align with their values and goals. This ensures respect for client autonomy.
C. Suggesting the “best” course of action for indecisive clients undermines their autonomy and is not consistent with advocacy. Advocacy means guiding and supporting, not making decisions on behalf of the client unless they lack decisional capacity.
D. Adhering strictly to the provider’s prescribed treatments is part of nursing care but does not reflect advocacy, which may involve questioning or clarifying orders if they conflict with the client’s wishes or best interests.
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