A nurse is delegating care for a group of four clients. Which of the following tasks should the nurse delegate to an assistive personnel (AP)?
Irrigate and perform a dressing change for a client who has a pressure injury wound.
Administer oral PRN pain medication to a client who has arthritis.
Obtain a daily weight on a client who has heart failure.
Reinforce teaching the use of an incentive spirometer to a postoperative client.
The Correct Answer is C
Choice A reason: Irrigating and performing a dressing change for a client who has a pressure injury wound is not a task that the nurse should delegate to an AP. This task requires the nurse's clinical judgment, skill, and knowledge to assess the wound, select the appropriate dressing, and prevent infection. This task is also within the nurse's scope of practice, but not the AP's scope of practice.
Choice B reason: Administering oral PRN pain medication to a client who has arthritis is not a task that the nurse should delegate to an AP. This task involves the nurse's responsibility to evaluate the client's pain level, determine the need and the dosage of the medication, and monitor the client's response and side effects. This task is also within the nurse's scope of practice, but not the AP's scope of practice.
Choice C reason: Obtaining a daily weight on a client who has heart failure is a task that the nurse can delegate to an AP. This task is a routine and standardized procedure that does not require the nurse's clinical judgment, skill, or knowledge. This task is also within the AP's scope of practice, if the nurse provides clear directions and supervision.
Choice D reason: Reinforcing teaching the use of an incentive spirometer to a postoperative client is not a task that the nurse should delegate to an AP. This task involves the nurse's role to educate the client about the purpose, benefits, and technique of using the incentive spirometer, and to evaluate the client's understanding and compliance. This task is also within the nurse's scope of practice, but not the AP's scope of practice.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: SOAP documentation is not the correct method for documenting only unexpected findings. SOAP documentation requires the nurse to document both normal and abnormal findings, as well as the plan of care for the client.
Choice B reason: Problem oriented medical record (POMR) is not the correct method for documenting only unexpected findings. POMR is a method that organizes the documentation around the client's problems, rather than the source of data. It consists of four components: database, problem list, plan, and progress notes.
Choice C reason: Focus charting (DAR) is not the correct method for documenting only unexpected findings. Focus charting is a method that uses the nursing process and the client's perspective to document the client's care. It consists of three components: data, action, and response.
Choice D reason: Charting by exception (CBE) is the correct method for documenting only unexpected findings. CBE is a method that assumes that all standards of care are met unless otherwise documented. It allows the nurse to document only significant or abnormal findings, such as changes in the client's condition, interventions, or outcomes.
Correct Answer is B
Explanation
Choice A reason: Client's skin is pale and diaphoretic is not included in the subjective component, but in the objective component. The objective component records the measurable and observable data that the nurse collects from the client, such as vital signs, physical examination findings, and laboratory results.
Choice B reason: Client reports chest pain after mowing lawn this morning is included in the subjective component. The subjective component records the data that the client verbalizes or expresses, such as symptoms, feelings, preferences, and beliefs.
Choice C reason: Client administered nitroglycerin 0.3 mg SL for chest pain is not included in the subjective component, but in the plan component. The plan component records the interventions and actions that the nurse implements or plans to implement for the client, such as medications, treatments, referrals, and education.
Choice D reason: Client's blood pressure is 182/98 mm Hg is not included in the subjective component, but in the objective component. The objective component records the measurable and observable data that the nurse collects from the client, such as vital signs, physical examination findings, and laboratory results.
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