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 D

Explanation

A. This is a standard intervention for phototherapy, as it helps to protect the eyes from excessive light exposure.
B. Check the neurovascular status every 4 hr of a child who had a hip spica cast placed 6 hr ago. This is a necessary intervention to monitor for potential complications, such as compartment syndrome, after a cast is applied.
C. Administer a bronchodilator two times a day for child who has cystic fibrosis. This is a common treatment for cystic fibrosis, as bronchodilators help to open the airways and improve breathing.
D. This is an inflammatory bowel disease characterized by inflammation of the large intestine. During an exacerbation, the goal is to reduce inflammation and promote healing. While a low-fiber diet may be helpful during an acute exacerbation to reduce bowel irritation, a high-protein diet is not recommended.

A. Instruct the newly licensed nurse to complete an incident report. B. Document the incident in the client's medical record. C. Provide the client with information about the incident. D. Communicate the incident to the nurse manager.

Correct Answer is D

Explanation

A. While completing an incident report is important for documenting the event, the witness should not instruct the newly licensed nurse to do so. Instead, it is the responsibility of the observer (the witness nurse) to report the incident to the appropriate authority to ensure that it is addressed properly.
B. Documenting the incident in the client's medical record is not appropriate in this case. The client’s medical record should only contain information relevant to the client’s care and treatment, not details about medication errors or policy violations.
C. While transparency is important, directly informing the client about a medication error is not typically the responsibility of the witnessing nurse. The primary focus should be on addressing the immediate issue and ensuring it is reported to the appropriate authorities rather than discussing the incident with the client.
D. The nurse manager is responsible for overseeing the unit and addressing incidents such as medication errors. Reporting the incident to the nurse manager ensures that it is investigated according to facility protocols.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is D

Explanation

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