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

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

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

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

Suctioning a client's long-term tracheostomy

Answer and Explanation

The Correct Answer is A

Choice A reason: Using a pain rating scale to monitor a client's pain level is a task that the nurse can delegate to an assistive personnel, as it does not require clinical judgment or specialized skills. The assistive personnel can report the pain score to the nurse, who can then adjust the pain management plan accordingly.

Choice B reason: Instructing a client on self-administration of a tap water enema is a task that the nurse cannot delegate to an assistive personnel, as it requires teaching and evaluation skills. The nurse should instruct the client on the procedure, the rationale, and the expected outcomes, and assess the client's understanding and ability to perform the task.

Choice C reason: Performing a dressing change on a client's peripherally inserted central catheter is a task that the nurse cannot delegate to an assistive personnel, as it requires sterile technique and infection control skills. The nurse should perform the dressing change according to the facility protocol, and monitor the site for any signs of complications.

Choice D reason: Suctioning a client's long-term tracheostomy is a task that the nurse cannot delegate to an assistive personnel, as it requires advanced airway management skills. The nurse should suction the client's tracheostomy as needed, and observe the client for any signs of respiratory distress.

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Correct Answer is D

Explanation

Choice A reason: Closing the fire doors and the doors to the room is an appropriate action, but not the first one that the nurse should take. The nurse should first activate the fire alarm to alert the fire department and the facility staff.

Choice B reason: Extinguishing the fire is an appropriate action, but not the first one that the nurse should take. The nurse should first activate the fire alarm to alert the fire department and the facility staff. Then, the nurse should use the fire extinguisher to put out the fire, following the RACE protocol (rescue, alarm, contain, extinguish).

Choice C reason: Removing clients from nearby rooms is an appropriate action, but not the first one that the nurse should take. The nurse should first activate the fire alarm to alert the fire department and the facility staff. Then, the nurse should evacuate the clients who are in immediate danger, following the RACE protocol (rescue, alarm, contain, extinguish).

Choice D reason: Activating the fire alarm is the first and most appropriate action that the nurse should take. The nurse should activate the fire alarm to alert the fire department and the facility staff. Then, the nurse should follow the RACE protocol (rescue, alarm, contain, extinguish) to protect the clients and the facility.

A. Client who has a displaced femur fracture from a fall B. Client who is experiencing severe vomiting and diarrhea with tachycardia C. Client who is confused and has slurred speech D. Client who has chemical burns covering 20% of the total body surface area

Correct Answer is C

Explanation

Choice A reason: A client who has a displaced femur fracture from a fall is a priority client, but not the highest priority. The nurse should assess the client for signs of bleeding, infection, nerve damage, and compartment syndrome, and provide pain relief and immobilization. However, the client's condition is not as urgent or life-threatening as the other clients.

Choice B reason: A client who is experiencing severe vomiting and diarrhea with tachycardia is a priority client, but not the highest priority. The nurse should assess the client for signs of dehydration, electrolyte imbalance, and shock, and provide fluid and electrolyte replacement and antiemetic medication. However, the client's condition is not as urgent or life-threatening as the other clients.

Choice C reason: A client who is confused and has slurred speech is the highest priority client, as these are signs of a possible stroke, which is a medical emergency. The nurse should assess the client for other signs of stroke, such as facial drooping, arm weakness, and vision problems, and initiate the stroke protocol, which includes calling for help, obtaining a CT scan, and administering thrombolytic therapy if indicated.

Choice D reason: A client who has chemical burns covering 20% of the total body surface area is a priority client, but not the highest priority. The nurse should assess the client for signs of airway injury, infection, and fluid loss, and provide wound care, pain relief, and fluid resuscitation. However, the client's condition is not as urgent or life-threatening as the other clients.

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