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. Notifying the unit manager should happen but discussing the issue with the AP directly is the initial step in addressing the problem.
B. Alerting the infection control department is important, but direct communication with the AP should come first to address the immediate concern.
C. Speaking with the AP allows for immediate clarification and correction of the behavior, aiming to prevent further incidents.
D. Reinforcing facility protocols at a staff meeting is beneficial, but immediate correction at the individual level is more crucial to prevent recurrence of the issue.
Correct Answer is B
Explanation
- A: This client requires initial teaching, which is typically the responsibility of a registered nurse due to the educational aspect and the need to assess the client's understanding.
- B: Administering an enema is a task that falls within the scope of practice for a licensed practical nurse and does not require the advanced assessment skills of a registered nurse.
- C: Developing an initial plan of care involves comprehensive assessment and critical thinking, which are responsibilities of a registered nurse.
- D: A client transferring from the CCU after a myocardial infarction would require close monitoring and assessment, which are beyond the scope of practice for a licensed practical nurse.
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