A nurse is planning care and identifying tasks to delegate. Which tasks are appropriate for a nurse to delegate to assistive personnel (AP)? Select all that apply

A.Reminding a client to perform a previously taught task, such as incentive spirometry, is a reinforcement of a stable plan of care and is appropriate for assistive personnel. The AP is not teaching the client the technique or assessing the physiological outcome, but rather providing a verbal prompt to encourage compliance. This allows the nurse to focus on the initial education and the clinical interpretation of the client's respiratory progress.

B.Monitoring and interpreting arterial blood gas (ABG) values is a highly complex task that requires advanced clinical knowledge of acid-base balance and respiratory physiology. This task falls strictly within the scope of practice of a registered nurse or respiratory therapist and cannot be delegated to unlicensed personnel. The nurse must analyze these results to determine the need for adjustments in oxygen therapy or mechanical ventilation settings.

C.Providing postmortem hygiene and preparing the body for viewing or transport is a standardized, non-invasive task that can be safely delegated to assistive personnel. The AP can perform the cleaning and positioning of the deceased while following facility protocols and maintaining dignity for the individual. The nurse remains responsible for the official declaration of death and providing emotional support to the grieving family members during the transition.

D.Measuring and recording a client's fluid intake and output is a routine technical task that is fundamental to the role of assistive personnel in various clinical settings. The AP can accurately collect data on oral intake, urine volume, and other measurable losses to assist in the assessment of fluid balance. The nurse then reviews and interprets this data to make clinical decisions regarding fluid replacement or diuretic therapy.

E.Checking intravenous (IV) sites for signs of infiltration, phlebitis, or infection requires the assessment skills and clinical judgment of a licensed nurse. Assistive personnel are not trained to identify the subtle nuances of skin discoloration, edema, or coolness that signify a failing IV access. The nurse must perform these checks personally to ensure the integrity of the vascular access and the safety of the medication administration.

A.Aspiration precautions are implemented for clients with dysphagia, impaired gag reflexes, or neurological conditions that affect swallowing mechanics. Iron deficiency anemia does not directly interfere with the esophageal or pharyngeal phases of deglutition. Unless the client has a co-occurring condition like a stroke, these precautions are not the primary focus for managing an anemia diagnosis.

B.Seizure precautions are necessary for clients with epilepsy, metabolic disturbances, or brain injuries that lower the seizure threshold. Iron deficiency anemia causes a decrease in hemoglobin and oxygen-carrying capacity but does not typically trigger abnormal electrical activity in the cerebral cortex. There is no clinical indication to initiate these precautions based solely on the laboratory diagnosis of anemia.

C.Iron deficiency anemia leads to reduced oxygen delivery to tissues, which often manifests as dizziness, orthostatic vertigo, and generalized muscle weakness. In an older adult, these symptoms significantly increase the risk of instability and accidental falls during daily activities. The nurse must implement fall precautions to mitigate the danger posed by the physiological effects of decreased hemoglobin levels.

D.Contact precautions are used to prevent the transmission of infectious agents such as MRSA or C. difficile via direct or indirect contact. Iron deficiency anemia is a non-communicable hematologic condition caused by nutritional deficits or chronic blood loss. Initiating contact precautions would be an inappropriate use of infection control resources and would unnecessarily restrict the client's social interactions.