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
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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Related Questions
Correct Answer is C
Explanation
A. A living will does not require approval from a physician; it is a legal document that outlines a person’s
wishes regarding medical treatment in case they become unable to communicate those wishes.
B. Advance directives should be completed while the individual is still capable of making informed decisions, ideally before a serious health issue arises. These documents are intended to provide
guidance on the person’s wishes regarding medical treatment and end-of-life care in situations where they might not be able to communicate their preferences.
C. The durable power of attorney for health care (also known as a health care proxy) is a component of advance directives. It designates a person to make medical decisions on behalf of the individual if they are unable to do so themselves. This document, along with a living will, is part of advance directives that help ensure a person’s health care wishes are honored.
D. A living will does not require a family member’s co-signature to be valid. It must be signed by the individual and may require witnessing or notarization depending on state laws, but not a family member’s co-signature.
Correct Answer is D
Explanation
A. By instructing the AP to stop discussing the client's care in a public area, the nurse helps prevent further exposure of sensitive information. However, while this step is necessary to immediately correct the behavior, it is not sufficient on its own to address the breach thoroughly.
B. This action is not appropriate as the primary responsibility for addressing a breach of confidentiality falls within the scope of nursing management and organizational policies, rather than the client's provider.
C. Reassigning the AP does not address the issue of confidentiality. The priority is to correct the behavior and ensure that such breaches do not occur in the future. Reassignment would not resolve the confidentiality breach or prevent further incidents.
D. This action is appropriate because it provides a formal mechanism to document the breach of confidentiality. Completing an incident report ensures that the issue is recorded and can be reviewed by management to address the breach and prevent future occurrences.
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