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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: The risk of suicide is the highest priority for the charge nurse to assess. The client has several risk factors for suicide, such as major depressive disorder, medication noncompliance, hopelessness, social isolation, and psychomotor retardation. The charge nurse should evaluate the client's suicidal ideation, intent, and plan, and implement safety measures as needed.
Choice B reason: The risk of dehydration is a lower priority than the risk of suicide. The client may be dehydrated due to decreased fluid intake, but this is not a life-threatening condition. The charge nurse should monitor the client's hydration status and encourage oral fluids as appropriate.
Choice C reason: The risk of infection is a lower priority than the risk of suicide. The client does not have any signs or symptoms of infection, such as fever, chills, or leukocytosis. The charge nurse should assess the client's vital signs and laboratory results as indicated, but this is not an urgent issue.
Choice D reason: The risk of seizure is a lower priority than the risk of suicide. The client does not have any history or risk factors for seizure, such as epilepsy, head trauma, or drug withdrawal. The charge nurse should observe the client for any abnormal movements or behaviors, but this is not a likely complication.
Correct Answer is B
Explanation
Choice A reason: A nurse refusing to actively participate during an elective abortion procedure scheduled for their client is not a behavior that indicates a need for further education. The nurse has the right to conscientious objection, which means they can decline to perform or assist in a procedure that violates their moral or religious beliefs. The nurse should inform the charge nurse of their objection and request to be reassigned to another client.
Choice B reason: A nurse explaining to a client's family that a DNR order includes withholding comfort measures is a behavior that indicates a need for further education. The nurse is providing false and misleading information that can cause harm and distress to the client and the family. A DNR order only means that no cardiopulmonary resuscitation (CPR) or advanced cardiac life support (ACLS) will be initiated in the event of a cardiac or respiratory arrest. A DNR order does not affect the provision of other treatments, such as pain management, hydration, nutrition, oxygen, or emotional support.
Choice C reason: A nurse informing a confused client who wants to go home that they are going to stay at the facility until they are better is not a behavior that indicates a need for further education. The nurse is using therapeutic communication and providing reassurance to the client. The nurse is also respecting the client's autonomy and right to refuse treatment, as long as the client is competent and informed. The nurse should assess the client's mental status and decision-making capacity, and involve the client's family or surrogate decision-maker if needed.
Choice D reason: A nurse giving prescribed opioids to a client who has a terminal illness and respirations of 8/min is not a behavior that indicates a need for further education. The nurse is following the principle of beneficence, which means doing good and preventing harm to the client. The nurse is also following the principle of double effect, which means that an action that has both a good and a bad effect is morally permissible if the good effect outweighs the bad effect. The nurse is providing adequate pain relief to the client, even if it may hasten their death. The nurse should monitor the client's vital signs and level of consciousness, and adjust the opioid dose as prescribed.
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