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 C
Explanation
Choice A reason: Use of restraints is not included in the outcome category, but in the process category. The process category measures the nursing interventions and activities that affect the client's health outcomes. Use of restraints is a nursing intervention that can have negative effects on the client's physical and psychological wellbeing, such as injuries, infections, agitation, and depression.
Choice B reason: Client admissions is not included in the outcome category, but in the structure category. The structure category measures the characteristics and resources of the health care setting that affect the quality of care. Client admissions is a characteristic that reflects the volume and complexity of the client population and the demand for nursing services.
Choice C reason: Hospital readmissions is included in the outcome category. The outcome category measures the results and consequences of the nursing care provided to the clients. Hospital readmissions is a result that indicates the effectiveness and continuity of the nursing care. A high rate of hospital readmissions can suggest poor quality of care, inadequate discharge planning, or lack of follow-up care.
Choice D reason: Staffing is not included in the outcome category, but in the structure category. The structure category measures the characteristics and resources of the health care setting that affect the quality of care. Staffing is a resource that reflects the quantity and quality of the nursing staff, such as the number, education, experience, and skill mix of the nurses.
Correct Answer is A
Explanation
Choice A reason: This action is correct because airway protection is the first priority for a client who is unconscious and has trauma to multiple systems. The nurse should assess the client's airway patency, breathing, and oxygenation, and intervene as needed to secure and maintain the airway. The nurse should also monitor the client for signs of aspiration, bleeding, or obstruction, and suction the airway as needed.
Choice B reason: This action is incorrect because stabilizing cardiac arrhythmias is not the first priority for a client who is unconscious and has trauma to multiple systems. The nurse should assess the client's circulation, blood pressure, and pulse, and intervene as needed to treat any arrhythmias, shock, or hemorrhage. However, this is not a priority over the client's airway, which is essential for survival.
Choice C reason: This action is incorrect because preventing musculoskeletal disability is not the first priority for a client who is unconscious and has trauma to multiple systems. The nurse should assess the client's mobility, sensation, and alignment, and intervene as needed to prevent or treat any fractures, dislocations, or nerve injuries. However, this is not a priority over the client's airway, which is essential for survival.
Choice D reason: This action is incorrect because decreasing intracranial pressure is not the first priority for a client who is unconscious and has trauma to multiple systems. The nurse should assess the client's level of consciousness, pupillary response, and neurological status, and intervene as needed to prevent or treat any increased intracranial pressure, cerebral edema, or brain injury. However, this is not a priority over the client's airway, which is essential for survival.
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