A nurse is delegating tasks to a group of staff members. Which of the following tasks should the nurse assign to an assistive personnel?

Irrigate a client's incision.

Determine a client's pain level.

Insert a nasogastric tube.

Provide postmortem care.

Answer and Explanation

The Correct Answer is D

A. Irrigate a client's incision: Wound irrigation is a sterile procedure that requires nursing judgment and skill to prevent infection and assess wound healing. This task should not be delegated to assistive personnel.

B. Determine a client's pain level: Assessing pain requires clinical judgment to interpret subjective and objective findings and evaluate the need for interventions. This responsibility remains with the licensed nurse.

C. Insert a nasogastric tube: Insertion of a nasogastric tube is an invasive procedure that requires nursing knowledge and technical skill to ensure proper placement and prevent complications. It is not within the scope of assistive personnel.

D. Provide postmortem care: Postmortem care is a noninvasive task that involves preparing the body, performing hygiene, and maintaining dignity. It falls within the scope of practice for assistive personnel and can be safely delegated.

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Correct Answer is A

Explanation

Rationale:

A. The child believes the person will return: Preschoolers view death as temporary and reversible due to their developmental stage and limited understanding of permanence. Magical thinking often leads them to expect the deceased person to come back.

B. The child focuses on his own mortality: This is more typical of older school-age children or adolescents, who have a more developed understanding of death’s permanence and may begin to consider their own vulnerability.

C. The child refuses to talk about the death: Avoidance can occur at any age, but it is not the primary expected response in preschoolers. At this stage, they may ask repetitive questions or make statements that suggest misunderstanding, rather than complete refusal to talk.

D. The child expresses curiosity about the death process: Curiosity about death’s physical aspects is more common in school-age children, who have greater cognitive ability to think concretely about biological processes.

A. Documenting communication with a provider in the progress notes of the client's medical record. B. Placing a yellow bracelet on a client who is at risk for falls. C. Administering potassium via iv bolus. D. Leaving a nasogastric tube clamped after administering oral medication.

Correct Answer is C

Explanation

A. Documenting communication with a provider in the progress notes of the client's medical record: Proper documentation of provider communication is standard nursing practice and does not constitute malpractice. It helps ensure continuity of care and legal protection.

B. Placing a yellow bracelet on a client who is at risk for falls: Implementing fall precautions, such as using a yellow wristband, is an appropriate safety measure and standard of care, not malpractice.

C. Administering potassium via IV bolus: Administering potassium as a rapid IV push is extremely dangerous and can cause cardiac arrest. This action violates the standard of care and constitutes malpractice due to potential harm to the client.

D. Leaving a nasogastric tube clamped after administering oral medication: A nasogastric (NG) tube is often clamped for a short period after administering medication to allow the medication to be absorbed. The nurse's action would only be considered negligent if they left the tube clamped for a prolonged period.

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