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A nurse on a hospice unit is planning care for 5 clients after receiving change-of-shift report

For which of the following 2 clients can the nurse delegate tasks to the AP?

Client 4

Client 3

Client 5

Client 1

Client 2

Answer and Explanation

Correct Answer : B,E

Rationale:

Client 3 – Post ischemic stroke, unresponsive: The tasks include repositioning every 2 hours, performing personal hygiene, and changing linens, which are routine, non-invasive care measures that can safely be delegated to an AP under supervision.
Client 5 – End-stage ovarian cancer with pain: The AP can assist with checking vital signs or basic comfort measures, such as repositioning or assisting with non-pharmacologic pain interventions. Tasks like assessing pain severity and reviewing medications must remain with the RN, but the AP can support comfort-related activities safely.
Client 1 – End-stage lung cancer with severe pain: The RN must administer morphine and provide teaching; these are complex tasks requiring clinical judgment and cannot be delegated.
Client 2 – Postmortem care: Postmortem care can be delegated in some settings, but the nurse typically leads the initial care, including documentation and verification, especially immediately after pronouncement.
Client 4 – COPD and COVID-19, refusing treatment: The RN must assess and develop the care plan, which requires clinical judgment and cannot be delegated to the AP.

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Correct Answer is C

Explanation

Rationale:
A. Discussing the incident with another staff nurse is inappropriate because it spreads information about the breach and does not address the issue directly. Confidentiality violations should be handled professionally and promptly with the individuals involved or through appropriate supervisory channels.

B. Reporting the staff members’ actions to the state board of nursing is excessive as a first step. State boards handle serious violations of nursing practice or legal regulations, but minor breaches of confidentiality are typically managed within the facility through counseling, education, or supervisory intervention first.

C. Counseling the staff members about the breach of confidentiality is the correct first action. The nurse should address the issue promptly by reminding staff of the Health Insurance Portability and Accountability Act (HIPAA) regulations and the organization’s policies on protecting patient information. Immediate corrective action at the unit level helps prevent further breaches and reinforces professional standards.

D. Filing a grievance report is not the first step. Grievances are formal complaints that may be used if counseling or direct intervention fails. Immediate, direct counseling is more appropriate for addressing a specific, observable incident like this.

A. Development of 53 heart sounds B. Decreased brain natriuretic peptide levels C. Presence of jugular vein distention D. Increased weight of 2.27 kg (5 lb) in one week

Correct Answer is B

Explanation

Rationale:
A. The development of an S3 heart sound is a sign of ventricular dysfunction or fluid overload in heart failure. This would indicate worsening cardiac status rather than success of the quality improvement initiative.

B. Decreased brain natriuretic peptide (BNP) levels reflect improved cardiac function and reduced fluid overload. BNP is released in response to ventricular stretch, so lower levels indicate that heart failure is being better managed, which aligns with the goal of reducing readmissions. This is a positive outcome and demonstrates that the quality improvement initiative is effective.

C. Jugular vein distention (JVD) is a clinical sign of right-sided heart failure and fluid overload, indicating that the client’s heart failure is not optimally controlled. This finding would suggest the initiative may not be fully successful.

D. An increased weight of 2.27 kg (5 lb) in one week is an early indicator of fluid retention in heart failure. Rapid weight gain signals worsening volume overload, which would be a negative outcome and not indicative of success.

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A nurse on a hospice unit is planning care for 5 clients after receiving change-of-shift report For which of the following 2 clients can the nurse delegate tasks to the AP?

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Explanation

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Correct Answer is B

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A nurse on a hospice unit is planning care for 5 clients after receiving change-of-shift report

For which of the following 2 clients can the nurse delegate tasks to the AP?