A nurse is delegating obtaining the collection of a client's oral temperature to an assistive personnel (AP). The nurse notes in the documentation that the AP obtained the client's axillary temperature. Which of the following rights of delegation should have prevented this situation from occurring?

Right task

Right communication

Right person

Right circumstance

Answer and Explanation

The Correct Answer is A

A.   The right task involves ensuring that the delegated task is appropriate for delegation. In this case, obtaining an oral temperature should have been the correct task; however, the AP
performed the axillary temperature, indicating a deviation from the right task.
B.   Right communication involves clear and effective communication between the nurse and the assistive personnel but is not directly related to the task performed.
C.   Right person involves ensuring that the task is delegated to a competent and qualified

individual. The issue in this scenario is with the task itself, not the competency of the individual.

D. Right circumstance involves ensuring that the conditions are appropriate for delegation. While the circumstance is important, the primary concern in this case is the mismatch between the task and the method of temperature measurement.

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Correct Answer is C

Explanation

A. Sterile gloves are not necessary for a tap water enema; clean, non-sterile gloves are sufficient.

B. Lubricating the tip of the rectal tube is appropriate to ease insertion and enhance client comfort.
C. Placing the client into a left Sims' position facilitates optimal administration of a tap water enema.
D. Lowering, not raising, the enema bag will allow for a slower flow and may reduce cramping.

A. Provide the AP with a copy of the unit's policy. B. Notify the charge nurse about the incident. C. Talk with the AP about the technique used. D. Conduct an in-service on standard precautions.

Correct Answer is C

Explanation

A. Providing the AP with a copy of the unit's policy may be done but is not the first step. Direct communication is important for immediate feedback.
B. Notifying the charge nurse is appropriate but may not be the first action when direct communication with the AP can address the issue.
C. Talking with the AP about the technique used is the first and immediate action to address the observed lapse in infection control practices.
D. Conducting an in-service on standard precautions is a broader intervention and may be considered after addressing the immediate concern with the AP.

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A nurse is delegating obtaining the collection of a client's oral temperature to an assistive personnel (AP). The nurse notes in the documentation that the AP obtained the client's axillary temperature. Which of the following rights of delegation should have prevented this situation from occurring?

Nursing Test Bank

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