A nurse is reviewing the medical record of a client who has moderate Alzheimer's disease.
To effectively manage the provider prescriptions, which of the following tasks should the nurse assign to an assistive personnel (AP)?
Record strict nutritional content.
Administer memantine.
Perform neurological checks.
Continue bowel training program.
The Correct Answer is A
Choice A rationale
The task of recording strict nutritional content is within the scope of practice for an assistive personnel (AP). The AP can keep track of the client’s food and fluid intake and report this information to the nurse. This is important in this case as the client has not been eating and the provider has prescribed a regular tray with finger foods at each meal. The nurse can then use this information to assess the client’s nutritional status and make necessary adjustments to the care plan.
Choice B rationale
Administering medication, such as memantine, is not within the scope of practice for an AP. This task requires knowledge and skills related to pharmacology, assessment, and evaluation that are beyond the training of an AP. Therefore, this task should be performed by a licensed nurse.
Choice C rationale
Performing neurological checks is also not within the scope of practice for an AP. These checks involve assessing the client’s level of consciousness, orientation, and neurological function, which require advanced assessment skills. Therefore, this task should be performed by a licensed nurse.
Choice D rationale
Continuing the bowel training program could potentially be within the scope of practice for an AP, depending on the specific tasks involved. However, in this case, the family member has reported that the client is having more difficulty staying focused, which suggests that the bowel training program may need to be adjusted. This requires nursing judgment and therefore should be performed by a licensed nurse.
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Related Questions
Correct Answer is A
Explanation
Choice A rationale
The nurse should indeed consider the AP’s level of experience when making delegation decisions. This is because the level of experience can greatly influence the ability of the AP to perform the delegated tasks effectively and safely. An experienced AP may be more competent and confident in performing certain tasks compared to someone with less experience. Therefore, considering the AP’s level of experience is crucial in ensuring quality care for patients.
Choice B rationale
While it is true that APs can assist in providing client education about basic self-care, it is important to note that the scope of their teaching is limited. They can reinforce teaching done by the nurse but should not be the primary source of education, especially for complex care needs or new diagnoses. Therefore, this statement does not fully reflect effective delegation.
Choice C rationale
This statement is incorrect. Even when care is delegated to an AP, the nurse retains accountability for client outcomes. The nurse remains responsible for ensuring that the delegated tasks are completed correctly and safely. Therefore, this statement does not indicate effective delegation.
Choice D rationale
This statement is also incorrect. APs should not re-delegate tasks to another AP1. The nurse who delegated the task has assessed the competency and capabilities of the specific AP to whom the task was delegated. Re-delegation could lead to tasks being performed by someone who may not have the necessary skills or knowledge, potentially compromising patient safety.
Correct Answer is C
Explanation
Choice A rationale
Having the patient void is not the immediate priority. While it is important to ensure the bladder is not distended, which could interfere with labor progress, the vital signs suggest a more urgent concern.
Choice B rationale
Asking the patient if she needs pain medication is important for comfort measures during labor, but it is not the immediate priority. The nurse’s first responsibility is to ensure the safety of the mother and baby.
Choice C rationale
Turning the patient on her side and rechecking the blood pressure is the correct action. The maternal blood pressure is low, which could indicate supine hypotensive syndrome. This occurs when the gravid uterus compresses the inferior vena cava when the woman is supine, reducing venous return to the heart. Turning the woman on her side may relieve this pressure and improve blood pressure.
Choice D rationale
Notifying the healthcare provider of the findings is important, but it is not the first action the nurse should take. The nurse should first address the mother’s hypotension by turning her on her side.
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