A nurse is planning care for clients.
Which of the following tasks can the nurse delegate to an assistive personnel (AP)?

The correct answer is Choice C. Secure the restraints using a quick-release tie.

Choice A rationale: Anticipate removing the restraints every 4 hr. This is incorrect because restraints should be removed more frequently to assess the client's skin integrity, circulation, and overall need for continued restraint. Best practices typically suggest removing restraints every 2 hours for these checks.

Choice B rationale: Ensure four fingers fit under the restraints to prevent constriction. This is incorrect as well. The correct practice is to ensure that only two fingers can fit under the restraints. Allowing four fingers may lead to improper restraint, increasing the risk of injury or the restraint slipping off.

Choice C rationale: Secure the restraints using a quick-release tie. This is correct because quick-release ties are designed to allow rapid removal of restraints in case of emergency, ensuring the client's safety while also maintaining restraint effectiveness.

Choice D rationale: Secure the restraints to the lowest bar of the side rail. This is incorrect because restraints should never be secured to a movable part like the side rail, as it can cause injury if the rail is adjusted. Restraints should be secured to the bed frame, which is stable and stationary.

The correct answers are a. Client's hearing deficit, b. Volume of the client's television, c. Numerous visitors in the client's room, e. Adverse effects of opioid analgesic, and f. Using earphones while listening to music.

Choice A rationale: A client with hearing loss who does not wear a hearing aid may experience difficulty understanding spoken communication, especially in noisy environments, leading to potential miscommunication or misunderstanding.

Choice B rationale: Loud television volume can make it difficult for both the nurse and the client to hear each other, causing interference in their communication and potentially leading to errors in information exchange.

Choice C rationale: The presence of numerous visitors in the room can cause distractions, background noise, and overall interference with the nurse-client communication process, potentially affecting the quality and accuracy of the information exchanged.

Choice E rationale: Opioid analgesics can cause adverse effects such as drowsiness, confusion, or cognitive impairment, hindering effective communication between the nurse and the client, as the client's ability to comprehend, retain, and convey information may be impaired.

Choice F rationale: The use of earphones while listening to music can impair the client's ability to hear the nurse, creating a barrier to effective communication. This could potentially lead to missed or misunderstood information and, consequently, affect the quality of care.

Choice D rationale (Incorrect choice): While an increase in pain after ambulation could affect the client's mood, cooperation, and ability to engage in effective communication, it does not directly create a barrier to the nurse's ability to communicate with the client. Pain management is an essential aspect of postoperative care, and effective communication can actually facilitate pain assessment, management, and overall client well-being.