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 D

Explanation

Rationale for A: An open fracture of the femur is serious and requires prompt treatment, but it does not typically indicate an immediate life threat compared to other conditions.

Rationale for B: Periorbital ecchymosis can indicate facial trauma, but it is not necessarily life-threatening and would not be prioritized as emergent.

Rationale for C: A deep partial thickness burn on the lower extremities is significant and requires treatment, but unless the burn covers a large area or is complicated by other factors, it is not the most critical issue compared to respiratory or cardiovascular threats.

Rationale for D: An asymmetrical thorax may suggest a possible pneumothorax or other significant respiratory issue, which could lead to respiratory distress or failure. This client should be tagged as emergent due to the potential for rapid deterioration.

A. Incorporate gestures and hand signals when presenting information. B. Involve the client's partner to assist with the teaching session C. Validate understanding by interpreting the client's body language. D. Provide an interpreter when obtaining consent from the client.

Correct Answer is D

Explanation

A. Gestures and hand signals can be helpful but might not fully convey complex medical information.
B. Involving the client's partner can be beneficial but might not ensure accurate communication and understanding.
C. Interpreting body language is essential for communication but might not suffice for comprehensive teaching.
D. Providing an interpreter ensures accurate and complete communication during the teaching session, facilitating understanding and informed consent.

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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

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