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 B

Explanation

Choice A reason: Contacting the client's next of kin to obtain consent for treatment is not a correct action, as it may delay the necessary and urgent care for the client. The nurse should assume that the client would consent to life-saving treatment and act in the client's best interest.

Choice B reason: Proceeding with treatment without obtaining written consent is the correct action, as it is justified by the emergency doctrine. The nurse should provide immediate and appropriate care for the client who is unable to give consent due to their condition.

Choice C reason: Having the client sign a consent for treatment is not a correct action, as the client is disoriented and cannot give informed consent. The nurse should not ask the client to sign any documents that they may not understand or remember.

Choice D reason: Notifying risk management before initiating treatment is not a correct action, as it is not a priority in an emergency situation. The nurse should focus on the client's needs and safety and document the care provided and the rationale for the actions taken.

A. Increase in serosanguineous exudate from a client's wound B. Deep red color on the center of a client's wound C. Erythema on the skin surrounding a client's wound D. Inflammation noted on the tissue edges of a client's wound

Correct Answer is B

Explanation

Choice A reason: This is not the correct choice because an increase in serosanguineous exudate (a mixture of blood and clear fluid) from a client's wound indicates infection, inflammation, or trauma to the wound. This is a sign of wound deterioration, not healing.

Choice B reason: This is the correct choice because a deep red color on the center of a client's wound indicates granulation tissue, which is new tissue that forms during the healing process. Granulation tissue fills the wound bed and provides a foundation for epithelialization (the growth of new skin over the wound).

Choice C reason: This is not the correct choice because erythema (redness) on the skin surrounding a client's wound indicates irritation, inflammation, or infection of the skin. This is a sign of wound complication, not healing.

Choice D reason: This is not the correct choice because inflammation on the tissue edges of a client's wound indicates infection, trauma, or necrosis (death) of the tissue. This is a sign of wound impairment, not healing.

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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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