A nurse is delegating care for a client who has right-sided weakness following a cerebrovascular accident. The client coughs when eating and voice becomes hoarse after swallowing. Select the four tasks the nurse should assign to an assistive personnel.
Ambulate the client.
Document the client's urine output.
Assist the client with completing their food menu.
Instruct the client on swallowing techniques.
Obtain the client's vital signs.
Refer the client to the speech language pathologist
Correct Answer : A,B,C,E
Choice A: Ambulate the client
Ambulating the client is a task that can be safely delegated to assistive personnel. The client has right-sided weakness following a cerebrovascular accident, and assistive personnel can help the client move around safely¹.
Choice B: Document the client's urine output
Documenting the client's urine output is another task that can be delegated to assistive personnel. They are trained to measure and record urine output, which is important for monitoring the client's fluid balance¹.
Choice C: Assist the client with completing their food menu
Assistive personnel can also help the client with completing their food menu. This task does not require clinical judgement and can be safely delegated¹.
Choice D: Instruct the client on swallowing techniques
Instructing the client on swallowing techniques should not be delegated to assistive personnel. This task requires specialized knowledge and skills that are beyond the scope of practice for assistive personnel².
Choice E: Obtain the client's vital signs
Obtaining the client's vital signs is a task that can be delegated to assistive personnel. They are trained to accurately measure and record vital signs, which are crucial for monitoring the client's health status¹.
Choice F: Refer the client to the speech language pathologist
Referring the client to the speech language pathologist is not a task that can be delegated to assistive personnel. This decision requires clinical judgement and should be made by the nurse².
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Related Questions
Correct Answer is B
Explanation
Choice A reason: Purchasing primary tubing for IV therapy is not a cost-effective client care task, as it involves spending money on supplies that may not be necessary or appropriate for every client. The nurse should recommend using secondary tubing or changing the primary tubing according to the facility's policy and the client's condition.
Choice B reason: Implementing a fall prevention program is a cost-effective client care task, as it can prevent injuries, complications, and lawsuits that can result from client falls. The nurse should recommend using evidence-based strategies, such as assessing the client's fall risk, providing appropriate supervision and assistance, and using safety devices and alarms.
Choice C reason: Providing staff education on infection control is not a cost-effective client care task, as it involves investing time and resources on training that may not have a direct impact on the client's outcomes. The nurse should recommend following the standard precautions and the facility's protocol for infection prevention and control.
Choice D reason: Hiring a wound care specialist is not a cost-effective client care task, as it involves paying for an additional staff member who may not be needed or utilized for every client. The nurse should recommend providing wound care according to the provider's orders and the facility's guidelines, and consulting a wound care specialist only when necessary.
Correct Answer is D
Explanation
Choice A reason: The client must understand the risks and benefits of the proposed treatment is not information that the nurse should include in the teaching about implied consent. This is information that the nurse should include in the teaching about informed consent, which is a type of consent that requires the client's written or verbal agreement after receiving adequate information about the treatment.
Choice B reason: The nurse's signature indicates that they witnessed the client's signature is not information that the nurse should include in the teaching about implied consent. This is information that the nurse should include in the teaching about informed consent, which is a type of consent that requires the client's written or verbal agreement after receiving adequate information about the treatment.
Choice C reason: Consent can be verbal or written is not information that the nurse should include in the teaching about implied consent. This is information that the nurse should include in the teaching about informed consent, which is a type of consent that requires the client's written or verbal agreement after receiving adequate information about the treatment.
Choice D reason: Nonverbal behavior indicates agreement is information that the nurse should include in the teaching about implied consent. This is a type of consent that does not require the client's written or verbal agreement, but is based on the client's actions or circumstances. For example, if the client holds out their arm for a blood pressure measurement, they are giving implied consent for the procedure.
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