A nurse is making assignments for staff on an inpatient unit. Which of the following tasks can a nurse legally delegate to assistive personnel?

Obtaining the initial assessment of assigned clients

Educating a client and family members on home care

Changing a nonsterile dressing

Interpreting a client's diagnostic laboratory results

Answer and Explanation

The Correct Answer is C

Rationale:
A. Obtaining the initial assessment of assigned clients: The initial assessment requires nursing judgment and clinical decision-making, which are within the scope of practice of a registered nurse only. It involves data interpretation and establishing a baseline for care, tasks that cannot be delegated to assistive personnel.

B. Educating a client and family members on home care: Client and family teaching requires specialized nursing knowledge to ensure understanding and accuracy. This task involves evaluating learning needs and reinforcing critical information, responsibilities that cannot be legally delegated to assistive personnel.

C. Changing a nonsterile dressing: Assistive personnel can safely perform nonsterile procedures such as changing a clean dressing under the supervision of a nurse. This task involves routine care that does not require nursing judgment, making it appropriate for delegation.

D. Interpreting a client's diagnostic laboratory results: Interpretation of laboratory data involves analysis, clinical reasoning, and the ability to make informed nursing decisions. These actions fall strictly within the nurse’s professional scope of practice and cannot be delegated to assistive personnel.

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Free Nursing Study Resources

Correct Answer is B

Explanation

Rationale:
A. Tell the client they can continue to drink cranberry juice while taking warfarin: Cranberry juice can potentiate the effects of warfarin, increasing the risk of bleeding. Clients should be cautioned to avoid interactions that affect anticoagulation.

B. Consult the pharmacist about potential interactions between the client's regular medications and warfarin: Warfarin has numerous drug and food interactions that can significantly alter its effectiveness. Consulting a pharmacist ensures safe management of concurrent medications and reduces the risk of adverse effects.

C. Recommend the client take warfarin at the same time as other medications: While consistent dosing is important, the priority is verifying potential interactions with other medications rather than simply synchronizing administration times.

D. Advise the client that over-the-counter medications remain safe to consume as needed: Many OTC medications, such as NSAIDs, can increase bleeding risk when taken with warfarin. Clients should always check with their provider or pharmacist before using OTC products.

A. Oxygen saturation 97% on room air B. Pain level of 1 on a scale of 0 to 10 C. BMI 35 D. Capillary refill time 1 second

Correct Answer is C

Explanation

Rationale:
A. Oxygen saturation 97% on room air: Adequate oxygenation is essential for wound healing because oxygen supports collagen synthesis and tissue repair. An oxygen saturation of 97% indicates sufficient oxygen delivery to tissues and does not place the client at risk for delayed healing.

B. Pain level of 1 on a scale of 0 to 10: Minimal pain suggests effective postoperative pain management and allows the client to move, breathe deeply, and participate in recovery activities. Pain at this level does not negatively impact the wound-healing process.

C. BMI 35: Obesity is associated with delayed wound healing due to poor vascularity in adipose tissue, which reduces oxygen and nutrient delivery to the wound. Increased tension on wound edges and a higher risk of infection also contribute to impaired healing in obese clients.

D. Capillary refill time 1 second: A capillary refill of 1 second reflects adequate peripheral perfusion, which supports effective oxygen and nutrient delivery to tissues. Normal circulation facilitates the healing process rather than delaying it.

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A nurse is making assignments for staff on an inpatient unit. Which of the following tasks can a nurse legally delegate to assistive personnel?

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Naxlex Comprehensive Predictor Exams

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Explanation

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Correct Answer is C

Explanation

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