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: This is not an appropriate action by the staff nurse. The incident report should not be sent to the ethics committee, as it is not a part of the client's record and does not involve ethical issues. The incident report should be sent to the risk management department, which is responsible for identifying and preventing potential hazards and liabilities in the health care setting.

Choice B reason: This is not an appropriate action by the staff nurse. The names of witnesses to the fall should not be listed in the nurses' notes, as they are not relevant to the client's care and may violate confidentiality. The names of witnesses should be included in the incident report, which is a confidential document that is not part of the client's record.

Choice C reason: This is an appropriate action by the staff nurse. The client's account of the fall should be included in the incident report, as it provides valuable information about the circumstances and causes of the fall. The incident report should also include the date, time, location, and description of the fall, the staff members involved, the interventions taken, and the client's condition and response.

Choice D reason: This is not an appropriate action by the staff nurse. The fact that an incident report was filed should not be documented in the client's record, as it may imply negligence or fault and may be used as evidence in a legal case. The incident report is a separate document that is used for quality improvement and risk management purposes.

A. Has data been collected about specific client needs related to turning? B. Does the AP have time to change the client's central IV line dressing after turning her? C. Has the AP checked the client's pain level prior to turning her? D. Is the client's family present so the AP can show them how to turn the client?

Correct Answer is C

Explanation

Choice A reason: Data collection about specific client needs related to turning is not an assessment that the nurse should make before delegating care, but rather a task that the nurse should perform and communicate to the AP. The nurse should identify the client's risk factors, preferences, and goals for turning and share them with the AP.

Choice B reason: Changing the client's central IV line dressing is not a task that the nurse should delegate to the AP, as it requires sterile technique and infection control. The nurse should perform this task and document the findings and interventions.

Choice C reason: Checking the client's pain level prior to turning her is an assessment that the nurse should make before delegating care, as it affects the client's comfort and safety. The nurse should ensure that the client's pain is adequately managed and that the AP is aware of the client's pain status and medication regimen.

Choice D reason: The presence of the client's family is not an assessment that the nurse should make before delegating care, but rather a factor that the nurse should consider and respect when planning and implementing care. The nurse should involve the client's family in the care process as much as possible and provide them with education and support.

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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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