A nurse is caring for four clients and is delegating tasks to an assistive personnel (AP). Which of the following tasks should the nurse plan to have the AP perform?

Provide postmortem care for a client who died 1 hr ago.

Reinforce discharge instructions with a client who is 2 days postoperative following an appendectomy.

Interpret deviations in a client's vital signs.

Insert an NG tube for a client who has difficulty eating.

Answer and Explanation

The Correct Answer is A

A. Providing postmortem care is a task that can be delegated to assistive personnel, as it involves following established protocols and does not require clinical judgment.
B. Reinforcing discharge instructions requires clinical knowledge and assessment, making it inappropriate for delegation to an AP.
C. Interpreting deviations in a client's vital signs necessitates nursing judgment and clinical expertise, which an AP does not possess.
D. Inserting an NG tube is a skilled nursing procedure that requires assessment and decision-making, thus it should not be delegated to an AP.

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Correct Answer is A

Explanation

A. Ecchymoses (bruising) over the buttocks and lower back in an older adult could be a sign of physical abuse or an underlying bleeding disorder, and it should be reported immediately.
B. Hirsutism, or increased facial and chest hair, is a common age-related change and does not usually require reporting unless it indicates an endocrine disorder.
C. Reduced skin elasticity is a normal age-related finding due to decreased collagen and elastin in aging skin.
D. Increased macules, or age spots, are benign and typical with aging, especially with prolonged sun exposure, and do not require reporting.

A. Obtain the client's capillary blood glucose level. B. Administer prescribed insulin. C. Provide the client's breakfast. D. Check the calibration of the glucometer.

Correct Answer is A

Explanation

A. Obtaining the client's capillary blood glucose level is the first action because it determines the appropriate timing and dosage of insulin administration, ensuring safe and effective diabetes management.
B. Administering prescribed insulin should occur after assessing the client's blood glucose level to avoid the risk of hypoglycemia or hyperglycemia.
C. Providing the client's breakfast is important but should only occur after assessing blood glucose and administering insulin as needed to maintain stable glucose levels.
D. Checking the calibration of the glucometer is essential for accurate readings but does not directly address the immediate need to assess the client's glucose level.

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A nurse is caring for four clients and is delegating tasks to an assistive personnel (AP). Which of the following tasks should the nurse plan to have the AP perform?

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