A nurse is planning to delegate client assignments to an assistive personnel. Which of the following tasks is appropriate for the nurse to delegate?

Collecting a urine specimen

Measuring a client's pain level

Monitoring blood glucose levels

Adjusting the flow rate of a client's oxygen tank

Answer and Explanation

The Correct Answer is A

A. Collecting a urine specimen: This task is routine, noninvasive, and does not require nursing judgment, making it appropriate for delegation to assistive personnel. APs are trained to obtain clean-catch or routine urine specimens while following proper technique. Delegating this task allows the nurse to focus on interventions requiring professional judgment.

B. Measuring a client's pain level: Pain assessment requires clinical judgment and involves interpreting verbal and nonverbal cues. Determining the severity, characteristics, and impact of pain is a nursing responsibility. Because it directly influences clinical decisions and interventions, it cannot be delegated to assistive personnel.

C. Monitoring blood glucose levels: Although APs in some settings may perform point-of-care glucose checks, this task generally requires specific training and competency validation. Interpretation of results and subsequent actions rely on nursing assessment, making it less appropriate for routine delegation unless the facility has clear protocols allowing it.

D. Adjusting the flow rate of a client's oxygen tank: Oxygen therapy adjustment involves evaluating the client’s respiratory status and making changes that can affect ventilation and oxygenation. Altering flow rates requires nursing judgment to ensure safety and prevent complications such as hypoxia or CO₂ retention.

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Correct Answer is D

Explanation

A. Atropine 4 mg IV stat: The dose of atropine is unusually high for typical adult administration, and documentation should include accurate dosing units and safety checks. Such a dose may indicate a potential medication error or require verification before administration.

B. Lorazepam 1.0 mg IV PRN every 6 hr: Using a trailing zero (1.0 mg) is unsafe because it can be misread as 10 mg, leading to overdose. Proper documentation avoids trailing zeros (e.g., 1 mg) and follows safe medication guidelines.

C. Sucralfate 1 g PO 1 hr ac: While the dose may be appropriate, abbreviations such as "ac" should be written out as "before meals" to prevent misinterpretation. Clear, unambiguous documentation is required for safe administration.

D. Enoxaparin 30 mg SC every 12 hr: This prescription uses correct dosing, route, frequency, and documentation format. It is clear, safe, and follows standard guidelines, making it the correct example of proper documentation.

A. Administer diphenhydramine 50 mg IM. B. Arrange for transport of the client to the nearest emergency department C. Apply cool, wet washcloths to the client's forehead and axilla. D. Administer fluphenazine decanoate in the client's deltoid. E. Instruct the client to discontinue risperidone

Correct Answer is ["A","B","C"]

Explanation

A. Administer diphenhydramine 50 mg IM: The client exhibits signs of neuroleptic malignant syndrome (NMS), including hyperthermia, autonomic instability, altered mental status, and muscle rigidity. Diphenhydramine can help manage extrapyramidal symptoms and muscle rigidity while stabilizing the client, making it an appropriate intervention in the acute phase.

B. Arrange for transport of the client to the nearest emergency department: NMS is a life-threatening medical emergency requiring immediate hospitalization for monitoring, intravenous fluids, and intensive management. The client’s elevated temperature, tachycardia, and altered mental status necessitate urgent transfer to a facility for providing acute care.

C. Apply cool, wet washcloths to the client's forehead and axilla: Hyperthermia is a critical component of NMS. Applying cool, wet washcloths provides non-pharmacologic fever management to reduce core body temperature while awaiting transport and additional treatment interventions. This helps prevent further complications such as organ failure.

D. Administer fluphenazine decanoate in the client's deltoid: Administering antipsychotics is contraindicated during NMS because these medications are the precipitating agents. Giving fluphenazine could worsen symptoms, increase rigidity, and exacerbate autonomic instability, so it must be avoided.

E. Instruct the client to discontinue risperidone: While antipsychotics should be discontinued in NMS, simply instructing the client to stop taking risperidone is insufficient. Immediate medical intervention and supervised discontinuation in a hospital setting are required due to the risk of rapid deterioration and life-threatening complications.

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A nurse is planning to delegate client assignments to an assistive personnel. Which of the following tasks is appropriate for the nurse to delegate?

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