A nurse on a medical-surgical unit is delegating client care. Which of the following tasks should the nurse delegate to an assistive personnel?

Instructing a client on self-administration of a tap water enema

Suctioning a client's long-term tracheostomy

Performing a dressing change on a client's peripherally inserted central catheter

Using a pain rating scale to monitor a client's pain level

Answer and Explanation

The Correct Answer is D

A.   Instructing a client on self-administration of a tap water enema involves providing education and guidance, which is within the scope of the nurse’s role. This task requires assessing the client’s understanding and ability to perform the procedure correctly.
B.   Suctioning a client’s long-term tracheostomy involves specialized skills and knowledge, including the ability to manage potential complications and assess the client’s respiratory status. This task should be performed by a registered nurse or a licensed practical nurse who has the necessary training and expertise.
C.   Changing the dressing on a PICC line involves sterile technique and specialized knowledge to prevent infection and ensure proper care of the central line. This task should be performed by a registered nurse or a licensed practical nurse with the appropriate training, as it requires assessment skills and adherence to infection control practices.
D.   Using a pain rating scale to monitor a client’s pain level is a task that can be safely delegated to assistive personnel. It involves asking the client to rate their pain and recording the response, which is a straightforward task that does not require advanced clinical judgment.

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Correct Answer is C

Explanation

A. Staffing issues are important as they can affect the workload and safety of the unit. However, the immediate concern is usually related to direct patient care. This situation should be addressed promptly to ensure coverage and proper delegation of tasks, but it is not the most urgent concern compared to issues directly affecting patient safety or emergency situations.
B. While this issue affects the logistical aspects of patient care, it is less critical compared to urgent patient care needs or emergencies. Arranging alternative transport solutions or rescheduling the therapy session should be addressed, but it is not as immediate as other concerns.
C. This situation should be addressed first because timely handoff of patient information is crucial for continuity of care. The new admission could require immediate attention, and a delay in receiving the report could impact patient care.
D. While an incident report about a medication error is significant and should be reviewed and addressed, it does not require immediate action in the same way that ensuring patient care continuity does. The charge nurse should review the incident report and follow up as necessary, but it is not as urgent as the need to receive a report on a new admission from the emergency department.

A. Close the fire doors and the doors to the clients' rooms. B. Extinguish the fire, C. Activate the fire alarm D. Remove all clients from the unit.

Correct Answer is C

Explanation

A. Closing fire doors and doors to clients' rooms is a good practice to contain smoke and fire. However, this action alone does not address the immediate needs of dealing with the fire or alerting others. It is an important step in the overall fire response, but it should follow other more immediate actions.
B. Extinguishing the fire is a critical step, but it comes after ensuring the safety of all individuals. If the nurse has already removed the client from the room, the next priority is to alert others and ensure that the fire is managed properly.
C. Activating the fire alarm is crucial because it alerts everyone in the building to the danger and initiates the building’s fire response protocols. This action should be taken as soon as possible to ensure that everyone in the building is aware of the emergency and can begin evacuating if necessary. It also ensures that emergency services are notified.
D. While removing all clients from the unit is extremely important, it is usually done as part of a coordinated response that includes alerting others and ensuring the safety of everyone in the building. The nurse should first activate the fire alarm and then work on evacuating all clients if it’s safe to do so.

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A nurse on a medical-surgical unit is delegating client care. Which of the following tasks should the nurse delegate to an assistive personnel?

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