A nurse is caring for a group of clients. Which of the following tasks should the nurse delegate to an assistive personnel? (Select all that apply.)

Changing a dressing for a client who has a stage 3 pressure injury

Obtaining a signed consent from a client for a screening colonoscopy

Measuring I &0 for a client who is receiving parenteral nutrition

Providing postmortem care for a client who experienced cardiac arrest

Transferring a client from a bed to a chair with a mechanical lift

Answer and Explanation

Correct Answer : D,E

A. Changing a dressing for a client who has a stage 3 pressure injury: Dressing changes for complex wounds require assessment of the wound, evaluation for signs of infection, and clinical judgment to select appropriate interventions. These responsibilities fall within the nurse’s scope of practice and should not be delegated to assistive personnel.

B. Obtaining a signed consent from a client for a screening colonoscopy: Obtaining informed consent involves explaining the procedure, risks, benefits, and answering client questions, which requires nursing knowledge and legal responsibility. This task cannot be delegated to assistive personnel.

C. Measuring I&O for a client who is receiving parenteral nutrition: Monitoring and documenting intake and output for a client receiving parenteral nutrition involves critical interpretation of fluid balance, which may affect electrolyte management and therapy adjustments. This task requires nursing judgment and is not appropriate for delegation.

D. Providing postmortem care for a client who experienced cardiac arrest: Postmortem care is a routine, noninvasive task that does not require nursing judgment. Assistive personnel can perform this task, including cleaning and positioning the body and preparing the client for the family, making it appropriate for delegation.

E. Transferring a client from a bed to a chair with a mechanical lift: Assisting with safe client mobility using a mechanical lift is within the scope of an assistive personnel’s role. This task does not require clinical decision-making but ensures safety and proper technique, making it suitable for delegation.

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Correct Answer is C

Explanation

A. Type 1 diabetes mellitus: Type 1 diabetes is not directly linked to an increased risk of cervical cancer. While chronic illnesses can affect overall health, they are not specific risk factors for cervical neoplasia.

B. Hypertension: Hypertension is a cardiovascular condition and does not contribute to the development of cervical cancer. It is not considered a risk factor in gynecologic oncology.

C. History of STIs: A history of sexually transmitted infections, particularly human papillomavirus (HPV), is a major risk factor for cervical cancer. HPV infection can cause cellular changes in the cervix that may progress to malignancy if not detected and managed early.

D. Nulliparity: While nulliparity has been associated with a slightly increased risk in some cancers, it is not as significant a risk factor for cervical cancer as HPV or other STIs. The primary focus in cervical cancer risk assessment is exposure to HPV.

A. Set up the sterile field 7.6 cm (3 in) below waist level. B. Hold the bottle of sterile solution with the palm over the label while pouring C. Place the sterile items within 1 cm (0.4 in) of the edge of the sterile border. D. Place the lid of a bottle of sterile solution within the sterile field.

Correct Answer is B

Explanation

A. Set up the sterile field 7.6 cm (3 in) below waist level: Sterile fields should be positioned at or above waist level to maintain sterility. Setting up below waist level increases the risk of contamination from accidental contact or spills.

B. Hold the bottle of sterile solution with the palm over the label while pouring: Covering the label with the palm prevents the solution from dripping onto the label and contaminating it. This ensures that the exterior of the bottle remains clean while maintaining sterility of the fluid being poured.

C. Place the sterile items within 1 cm (0.4 in) of the edge of the sterile border: The outer 1–2.5 cm (approximately 0.4–1 in) of a sterile field is considered nonsterile. Placing items too close to the edge risks contamination, so sterile items should be kept well within the borders.

D. Place the lid of a bottle of sterile solution within the sterile field: The inside of the lid is sterile only while in the upright position on the bottle. Placing it on the sterile field exposes it to potential contamination and is not recommended practice.

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