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 A

Explanation

Choice A reason: Collecting the client's urine output every 24 hours is a task that the nurse can delegate to an AP. This task is within the AP's scope of practice and does not require clinical judgment or assessment. The nurse should provide clear instructions and expectations to the AP, and monitor and evaluate the client's fluid status and renal function.

Choice B reason: Administering the client's scheduled antitubercular medications is a task that the nurse cannot delegate to an AP. This task is outside the AP's scope of practice and requires clinical judgment and assessment. The nurse should follow the five rights of medication administration and monitor the client for adverse effects and therapeutic outcomes.

Choice C reason: Assisting the client with speech therapy exercises is a task that the nurse cannot delegate to an AP. This task is outside the AP's scope of practice and requires specialized knowledge and skills. The nurse should collaborate with the speech therapist and follow the prescribed plan of care for the client.

Choice D reason: Placing the client on airborne precautions is a task that the nurse cannot delegate to an AP. This task is outside the AP's scope of practice and requires clinical judgment and assessment. The nurse should implement the infection control measures and educate the client and the AP about the rationale and the procedures.

A. Ambulate the client. B. Document the client's urine output. C. Assist the client with completing their food menu. D. Instruct the client on swallowing techniques. E. Obtain the client's vital signs. F. Refer the client to the speech language pathologist

Correct Answer is ["A","B","C","E"]

Explanation

Choice A: Ambulate the client

Ambulating the client is a task that can be safely delegated to assistive personnel. The client has right-sided weakness following a cerebrovascular accident, and assistive personnel can help the client move around safely¹.

Choice B: Document the client's urine output

Documenting the client's urine output is another task that can be delegated to assistive personnel. They are trained to measure and record urine output, which is important for monitoring the client's fluid balance¹.

Choice C: Assist the client with completing their food menu

Assistive personnel can also help the client with completing their food menu. This task does not require clinical judgement and can be safely delegated¹.

Choice D: Instruct the client on swallowing techniques

Instructing the client on swallowing techniques should not be delegated to assistive personnel. This task requires specialized knowledge and skills that are beyond the scope of practice for assistive personnel².

Choice E: Obtain the client's vital signs

Obtaining the client's vital signs is a task that can be delegated to assistive personnel. They are trained to accurately measure and record vital signs, which are crucial for monitoring the client's health status¹.

Choice F: Refer the client to the speech language pathologist

Referring the client to the speech language pathologist is not a task that can be delegated to assistive personnel. This decision requires clinical judgement and should be made by the nurse².

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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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Correct Answer is A

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Correct Answer is ["A","B","C","E"]

Explanation

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