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

Suctioning a client's long-term tracheostomy

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

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

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

Answer and Explanation

The Correct Answer is B

The correct answer is: B.

Choice A reason:

Suctioning a client's long-term tracheostomy is a complex procedure that involves sterile technique and assessment skills that are beyond the scope of assistive personnel's practice. It requires clinical judgment and the ability to respond to complications, which are responsibilities typically reserved for licensed nursing staff.

Choice B reason:

Using a pain rating scale to monitor a client's pain level is a task that can be delegated to assistive personnel. It involves asking the client to rate their pain on a scale, which does not require clinical judgment or advanced skills. The assistive personnel can then report the pain level to the nurse, who will make decisions regarding pain management.

Choice C reason:

Performing a dressing change on a client's peripherally inserted central catheter (PICC) is not within the scope of assistive personnel. This task requires aseptic technique and knowledge of PICC line management to prevent infection and other complications, which are typically the responsibility of the registered nurse or licensed practical nurse.

Choice D reason:

Instructing a client on self-administration of a tap water enema involves teaching and assessment to ensure the client understands and can perform the procedure safely. This is a task that requires licensed nursing knowledge and skills to educate the client and evaluate their competency.

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Correct Answer is C

Explanation

Choice A reason: Asking the client's daughter to interpret the conversation is not a correct action, as it may compromise the accuracy and confidentiality of the information. The nurse should not use family members or friends as interpreters, as they may have biases, emotions, or personal agendas that could interfere with the communication.

Choice B reason: Talking loudly while facing the client is not a correct action, as it may be perceived as rude or aggressive by the client. The nurse should not assume that the client can understand them better by increasing the volume or using gestures, as these may have different meanings in different cultures.

Choice C reason: Accessing a language line to interpret what is being said is the correct action, as it ensures that the communication is clear, accurate, and respectful. The nurse should use a qualified interpreter who is familiar with the medical terminology and the cultural context of the client.

Choice D reason: Using a bilingual dictionary to translate is not a correct action, as it may be time-consuming and ineffective. The nurse should not rely on a dictionary or a translation app, as they may not capture the nuances or expressions of the language. The nurse should also avoid using medical jargon or slang that may not be understood by the client.

A. "The clinicians help reduce the severity of your wife's physical problems." B. "This service delivers meals and supplies to reduce your errands away from home." C. "It makes it possible for you to have some time away from caring for your wife." D. "This service offers psychological interventions during and after your wife's illness."

Correct Answer is C

Explanation

Choice A reason: This is not the correct choice because this response is inaccurate and misleading. Respite services do not provide medical care or treatment for the client, but rather temporary relief and support for the family caregivers. The nurse should not give false hope or unrealistic expectations to the client's partner.

Choice B reason: This is not the correct choice because this response is incomplete and vague. Respite services may include some practical assistance such as meal delivery or housekeeping, but their main purpose is to provide emotional and social support for the family caregivers. The nurse should explain how respite services can help the client's partner cope with the stress and challenges of caregiving.

Choice C reason: This is the correct choice because this response is accurate and clear. Respite services can provide the client's partner with some time off from their caregiving duties, which can help them recharge their energy, attend to their own needs, and maintain their well-being. The nurse should emphasize the benefits of respite services for the client's partner and their relationship with the client.

Choice D reason: This is not the correct choice because this response is confusing and irrelevant. Respite services do not offer psychological interventions for the client or the family, but rather companionship and support. The nurse should not imply that the client's partner needs therapy or counseling, which may be perceived as judgmental or insensitive.

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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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