A nurse is instructing a newly licensed nurse about the scope and standards of nursing practice. Which of the following describes standards of practice?

Choice A reason: This task is unsafe to assign to an AP, as it requires clinical judgment and critical thinking skills that are beyond the scope of practice of an AP. A confused surgical client who has multiple tubes may be at risk of complications such as infection, bleeding, or dislodgement of the tubes. The nurse is responsible for monitoring the client's condition, assessing the tubes' function and placement, and intervening as needed.

Choice B reason: This task is safe to assign to an AP, as it does not involve direct client care or clinical decision making. Providing postmortem care for a client who has died involves preparing the body for transport, removing any tubes or devices, and ensuring respect and dignity for the deceased and their family. The nurse should supervise and instruct the AP on how to perform this task according to the facility's policies and procedures.

Choice C reason: This task is safe to assign to an AP, as it is part of the basic care and comfort activities that an AP can perform under the nurse's delegation. Assisting a client to eat who has difficulty seeing the foods on the tray involves helping the client identify the food items, cutting or opening them if needed, and encouraging adequate intake. The nurse should ensure that the client has no dietary restrictions or swallowing difficulties before assigning this task to the AP.

Choice D reason: This task is safe to assign to an AP, as it is a routine and noninvasive procedure that an AP can perform under the nurse's direction. Delivering a client’s urine specimen to the laboratory involves labeling the specimen container, placing it in a biohazard bag, and transporting it to the designated area. The nurse should provide the AP with clear instructions on how to collect and handle the specimen.

Choice A reason: This statement is false and should not be included in the teaching. Placing the client on 12hour observation is not enough to ensure the client's safety, as the client may still attempt suicide when the nurse is not watching. The client should be placed on continuous observation, preferably one-to-one, until the risk of suicide is reduced.

Choice B reason: This statement is false and should not be included in the teaching. Encouraging visitors to bring items to the client is not advisable, as some items may pose a potential danger to the client, such as sharp objects, medications, or alcohol. The nurse should inspect and limit the items that the client and the visitors have access to, and remove any items that could be used for self-harm.

Choice C reason: This statement is false and should not be included in the teaching. Encouraging visitors for the client at any time is not appropriate, as some visitors may have a negative impact on the client, such as those who are abusive, judgmental, or unsupportive. The nurse should screen and monitor the visitors, and allow only those who are helpful and respectful to the client.

Choice D reason: This statement is true and should be included in the teaching. Removing harmful objects from the client's room is a priority action that the nurse should take to prevent the client from harming themselves. The nurse should search the client's room and belongings, and remove any objects that could be used for suicide, such as knives, scissors, razors, belts, cords, or plastic bags.