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 C

Explanation

Choice A reason: The partner does not have the legal authority to make the care decision for the client, unless they are designated as the health care proxy or surrogate. The partner may have a personal or emotional interest in the client's well-being, but they cannot override the client's wishes or rights.

Choice B reason: The oldest adult child does not have the legal authority to make the care decision for the client, even though they have durable power of attorney. The durable power of attorney only becomes effective when the client is incapacitated or unable to make their own decisions. Since the client is oriented to person, place, and time, they are presumed to have the mental capacity to consent or refuse treatment.

Choice C reason: The client has the legal authority to make the care decision for themselves, as long as they are competent and informed. The client has the right to self-determination and autonomy, which means they can choose what is best for their own health and well-being. The client's decision should be respected and honored by the provider and the family members.

Choice D reason: The provider does not have the legal authority to make the care decision for the client, unless there is an emergency or a court order. The provider has the duty to inform the client of the benefits and risks of the surgery, and to obtain the client's consent before proceeding. The provider cannot coerce or force the client to undergo the surgery against their will.

A. A client who has a compromised airway B. A client who has major burns covering 70% of their body C. A client who experienced a brief loss of consciousness D. A client who has fixed pupils

Correct Answer is A

Explanation

Choice A reason: A client who has a compromised airway is in immediate danger of death and requires urgent attention. A red tag indicates that the client has a life-threatening condition and needs the highest priority of care.

Choice B reason: A client who has major burns covering 70% of their body is in critical condition and needs intensive care. However, they are not as urgent as a client who has a compromised airway. A yellow tag indicates that the client has a serious condition and needs the second highest priority of care.

Choice C reason: A client who experienced a brief loss of consciousness may have a concussion or a head injury, but they are not in immediate danger of death. A green tag indicates that the client has a minor condition and needs the lowest priority of care.

Choice D reason: A client who has fixed pupils is likely dead or near death and has no chance of survival. A black tag indicates that the client is deceased or expectant and needs no care.

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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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Naxlex Comprehensive Predictor Exams

Correct Answer is C

Explanation

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