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 A
Explanation
Choice A reason: Reminiscence therapy is a type of intervention that helps clients with Alzheimer's disease recall and share their past experiences, memories, and emotions. This can enhance their self-esteem, mood, and quality of life. By requesting a referral for this therapy, the nurse is advocating for the client's psychosocial needs and preferences.
Choice B reason: Performing an updated cognitive assessment on the client is not an example of advocacy, but rather a standard nursing practice. Cognitive assessments are used to monitor the client's cognitive status and progression of the disease. They do not necessarily reflect the client's wishes or interests.
Choice C reason: Providing assistance for the client when ambulating down the hall is not an example of advocacy, but rather a safety measure. The nurse is helping the client prevent falls and injuries, which are common risks for clients with Alzheimer's disease. This does not imply that the nurse is speaking up for the client or protecting their rights.
Choice D reason: Reorienting the client several times throughout the day is not an example of advocacy, but rather a therapeutic communication technique. The nurse is helping the client cope with confusion and disorientation, which are common symptoms of Alzheimer's disease. This does not indicate that the nurse is supporting the client's goals or values.
Correct Answer is B
Explanation
Choice A reason: The nurse puts on a face mask is not an action that demonstrates correct aseptic technique. This is an action that should be done before donning a sterile gown and gloves, not after. The nurse should wear a face mask to prevent contamination of the sterile field from respiratory droplets.
Choice B reason: The nurse holds her hands above her waist is an action that demonstrates correct aseptic technique. This is an action that prevents contamination of the sterile gloves from the non-sterile gown. The nurse should keep her hands above her waist and in front of her body at all times.
Choice C reason: The nurse turns her back to the sterile field is not an action that demonstrates correct aseptic technique. This is an action that causes contamination of the sterile field from the non-sterile back of the gown. The nurse should never turn her back to the sterile field or reach over it.
Choice D reason: The nurse touches the outside of the gown is not an action that demonstrates correct aseptic technique. This is an action that causes contamination of the sterile gloves from the non-sterile outside of the gown. The nurse should only touch the inside of the gown or other sterile items.
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