A nurse is delegating care for a client.
Exhibit 1
Nurses' Notes 1000:
Client has right sided weakness following a cerebrovascular accident. Client coughs when eating and voice becomes hoarse after swallowing. Select the 3tasks the nurse should assign to assistive personnel.
Assist the client with completing their food menu.
Document the client's urine output
Monitor the client for manifestations of aspiration pneumonia
initiate a referral with the speech language pathologist E. Instruct the client on swallowing techniques
Ambulate the client.
Obtain the client's vital signs.
Obtain the client's vital signs.
Correct Answer : B,F,G
Role of assistive personnel is activities of daily living, document input and output, obtain stable vitals as well assist clients in ambulating.
A. The choice of food should consider the risk of aspiration and should include soft food. The high-risk client needs the involvement of a nurse
C. Monitoring the client for features of aspiration pneumonia is in the scope of a registered nurse as it requires clinical judgment and knowledge. –
D. Initiating referral to a speech language pathologist is in the scope of a nurse.
E. Instructing on swallowing techniques is an intervention performed by nurses as it requires demonstration of safety techniques.
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Related Questions
Correct Answer is B
Explanation
As the healthcare surrogate, the partner is legally allowed to make decisions on behalf of the client. A healthcare surrogate is an individual upon whom the legal mandate is given to make healthcare decisions on behalf of the client in the event where the client lacks capacity to do so.
A. No further review of the advanced directives is necessary if the surrogate is known
C and D. If clearly stated, no further review by the facility committee or provider is needed as they undermine the role of the surrogate.
Correct Answer is D
Explanation
A cardiac arrhythmia is a medical emergency that require emergency intervention. The Emergency Medical Treatment and Active Labor Act (EMTALA) gives the nurse a legal obligation to offer the care required regardless of the availability of consent or funds.
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