A nurse is delegating care to assistive personnel. Which of the following assignments should the nurse make?

Reinforcing teaching with a client about stool specimen collection

Collecting a urine specimen from a client who is experiencing dysuria

Taking the vital signs of a client who is experiencing acute angina

Answering a telephone inquiry about NPO status from a client who is scheduled for a procedure

Answer and Explanation

The Correct Answer is B

A) Reinforcing teaching with a client about stool specimen collection:

This task involves providing education to the client, which requires nursing knowledge and judgment. It is not appropriate to delegate to assistive personnel, as they may not have the necessary training or expertise to provide accurate and comprehensive teaching.

B) Collecting a urine specimen from a client who is experiencing dysuria:

Collecting a urine specimen from a client who is experiencing dysuria is an appropriate task to delegate to assistive personnel. This task involves following a standard procedure for specimen collection and does not require specialized nursing judgment or assessment skills.

C) Taking the vital signs of a client who is experiencing acute angina:

Assessing vital signs, especially in a client experiencing acute angina, requires nursing judgment and the ability to recognize and respond to changes in the client's condition. This task should not be delegated to assistive personnel, as they may not have the training to recognize signs of deterioration or respond appropriately.

D) Answering a telephone inquiry about NPO status from a client who is scheduled for a procedure:

Providing information over the phone regarding NPO (nothing by mouth) status involves assessing the client's specific situation, understanding the procedure's requirements, and potentially making clinical decisions based on the client's condition. This task requires nursing judgment and should not be delegated to assistive personnel.

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Correct Answer is C

Explanation

A) The surgeon should delay surgery until he can obtain informed consent from a parent:

This option is not feasible in emergencies where immediate surgical intervention is required to save the client's life or prevent further harm. Delaying surgery could jeopardize the client's health and violate the principle of beneficence, which prioritizes the client's well-being.

B) The client's pediatrician can obtain implied consent:

While pediatricians often play a role in providing medical care to minors, implied consent typically pertains to emergency situations where immediate intervention is necessary, and obtaining consent from a parent or legal guardian is not possible. In this scenario, the surgeon, rather than the pediatrician, would be responsible for obtaining consent.

C) The surgeon can proceed with the surgery by invoking implied consent:

In emergency situations where immediate surgical intervention is required to prevent harm or save a client's life, healthcare providers may proceed with treatment under the doctrine of implied consent. Implied consent assumes that a reasonable person would consent to necessary medical treatment if they were able to do so. However, the specific legal requirements for invoking implied consent may vary depending on jurisdiction and institutional policies.

D) The surgeon can obtain informed consent from the client's adult cousin:

While obtaining consent from a close family member may be necessary in certain situations, such as when a parent is unavailable, it may not be legally sufficient in emergency situations where immediate action is required. Additionally, the legal authority to provide consent may vary depending on the jurisdiction and the client's age. In this scenario, relying on informed consent from the client's adult cousin could delay necessary surgical intervention and may not be appropriate without further legal clarification.

A. Select the appropriate dressing. B. Review available dressing types. C. Document the dressing change. D. Change the dressing.

Correct Answer is B

Explanation

A) Select the appropriate dressing:

Choosing the appropriate dressing is an essential step in the process of changing a wound dressing. However, before selecting a dressing, the nurse should first review the available dressing types to ensure that the choice is based on a comprehensive understanding of the client's wound characteristics, such as size, depth, exudate level, and presence of infection. Jumping straight to selecting a dressing without reviewing available options may result in choosing an inadequate or inappropriate dressing for the client's specific wound care needs.

B) Review available dressing types:

This is the most appropriate initial step in the process of changing a wound dressing. Before proceeding with the dressing change, the nurse should assess the client's wound and review the available dressing types to determine which one is most suitable. Factors to consider include the wound's characteristics, such as size, depth, and exudate level, as well as any specific requirements based on the stage of the pressure ulcer and the client's overall condition. Reviewing available dressing types ensures that the nurse makes an informed decision and selects the most appropriate dressing for promoting wound healing and preventing complications.

C) Document the dressing change:

Documentation is an essential aspect of wound care, as it provides a record of the client's progress, the interventions performed, and the client's response to treatment. While documenting the dressing change is important, it should occur after the dressing change itself. Documenting before completing the dressing change could lead to incomplete or inaccurate documentation, as the nurse may need to record details about the wound's appearance, the type of dressing used, and any observations made during the procedure.

D) Change the dressing:

Changing the dressing is a necessary step in the wound care process, but it should not be the first action taken without assessing the wound and reviewing available dressing options. Proceeding directly to changing the dressing without considering the client's specific wound care needs and available dressing types may result in suboptimal wound management and compromise the client's healing process.

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A nurse is delegating care to assistive personnel. Which of the following assignments should the nurse make?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is B

Explanation

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