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?
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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Contact precautions typically involve wearing gloves and a gown to prevent the spread of infectious agents through direct contact. Masks are not generally required for visitors unless the client is also on droplet or airborne precautions. Therefore, this statement reflects a misunderstanding of the specific requirements for contact precautions.
B.A client with compromised immunity should be placed in a positive-pressure airflow room, not a negative-pressure room. Positive-pressure rooms help prevent outside contaminants from entering the room, thereby protecting the immunocompromised client.
C. Clients on airborne precautions (e.g., for tuberculosis, varicella, or measles) should wear a mask if they need to leave their room to prevent the spread of airborne pathogens to others. This helps to contain infectious particles and protect others from exposure.
D. An N95 respirator mask is required for airborne precautions, not droplet precautions. For droplet precautions (e.g., for influenza, pertussis), a standard surgical mask is sufficient to protect against respiratory droplets.
Correct Answer is C
Explanation
A. Instructing the AP to request assistance when unsure about a task is important for future situations, but it does not immediately address the current incorrect transfer, which could pose a risk to the client.
B. Demonstrating the proper client transfer technique for the AP directly addresses the immediate issue, ensuring the client is safely transferred and the AP learns the correct method through observation and practice.
C. Helping the AP assist the client with the transfer ensures the client's safety in the moment, but it does not provide the AP with the knowledge or skills needed to perform the task correctly in the future.
D. Referring the AP to the facility procedure manual is useful for long-term learning, but it does not provide the immediate guidance needed to correct the current unsafe transfer.
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