A nurse is preparing to delegate bathing and turning of a newly admitted client who has end- stage bone cancer to an experienced assistive personnel (AP). Which of the following assessments should the nurse make before delegating care?

Is the client's family present so the AP can show them how to turn the client?

Has the AP checked the client's pain level prior to turning her?

Does the AP have time to change the client's central IV line dressing after turning her?

Has data been collected about specific client needs related to turning?

Answer and Explanation

The Correct Answer is D

A.   While involving the family might be beneficial for education, it's not directly related to assessing the client's needs for turning.
B.   Assessing the client's pain level is important, but it's only one aspect of comprehensive care when delegating turning to the AP.
C.   Checking the AP's availability for other tasks after turning the client is important but not the primary assessment before delegation.
D.   Before delegating care, the nurse should assess and collect data about the client's specific needs related to turning due to the client's condition. Understanding the client's condition and requirements for turning is crucial for effective delegation.

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Correct Answer is C

Explanation

A. Contacting the provider may be part of the process, but it does not directly address the conflict between the family members' wishes and the health care surrogate's legal authority.
B. While the ethics committee can be a valuable resource in resolving disputes, it is not the first step in this situation, as the health care surrogate has the legal right to make decisions on behalf of the unconscious client.
C. The health care surrogate is legally designated to make health care decisions for the client when they are unable to do so themselves. This includes decisions about life-sustaining treatments such as a feeding tube.
D. Reviewing the client's advance directives is important, but it does not supersede the authority of the health care surrogate unless the directives explicitly limit the surrogate's decision-making power.

A. Inform the unit manager of the incident. B. Speak with the AP about the incident. C. Remove the restraints from the client's wrists. D. Review the chart for nonrestraint alternatives for agitation,

Correct Answer is C

Explanation

A. Informing the unit manager is essential but not the first immediate action when a client is improperly restrained.
B. Speaking with the AP about the incident is important, but the priority is to ensure the client's safety and well-being.
C. Removing the restraints from the client's wrists is the first action to address the
inappropriate application of restraints without a prescription to ensure the client's safety and prevent harm.
D. Reviewing the chart for nonrestraint alternatives for agitation is important, but the priority is to address the immediate issue of the improperly applied restraints to the client.

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A nurse is preparing to delegate bathing and turning of a newly admitted client who has end- stage bone cancer to an experienced assistive personnel (AP). Which of the following assessments should the nurse make before delegating care?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is C

Explanation

A charge nurse making rounds observes that an assistive personnel (AP) has applied wrist restraints to a client who is agitated and does not have a prescription for restraints. Which of the following actions should the nurse take first?

Correct Answer is C

Explanation

A nurse enters the hallway and discovers a visitor looking at a client's medical information on a computer. Which of the following actions should the nurse take first?

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