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
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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Related Questions
Correct Answer is D
Explanation
Choice A reason: Beneficence is the ethical principle of doing good or acting in the best interest of others. While this is an important principle for nurses to follow, it does not directly apply to the situation of reporting the truth about the incident.
Choice B reason: Nonmaleficence is the ethical principle of avoiding harm or minimizing the risk of harm to others. This principle is relevant to the prevention of falls and the use of gait belts, but it does not address the issue of honesty in documentation.
Choice C reason: Fidelity is the ethical principle of being faithful or loyal to one's commitments and responsibilities. This principle relates to the nurse's duty to provide safe and competent care to the client, but it does not specify the obligation to report the facts accurately.
Choice D reason: Veracity is the ethical principle of telling the truth or being truthful. This principle is the most appropriate for the charge nurse to follow in this case, as it requires the nurse to report the incident honestly and completely, including the omission of the gait belt. This is essential for quality improvement, legal protection, and ethical accountability.
Correct Answer is C
Explanation
Choice A reason: This is not the correct choice because this response is insensitive and unprofessional. The nurse should not blame or criticize the client for signing the consent form, as this may make the client feel guilty or pressured. The nurse should respect the client's autonomy and right to change their mind.
Choice B reason: This is not the correct choice because this response is inadequate and irrelevant. The nurse should not assume that the client needs more information about the surgery, as this may not address the client's underlying reasons for being unsure. The nurse should listen to the client's concerns and provide emotional support.
Choice C reason: This is the correct choice because this response is respectful and reassuring. The nurse should acknowledge the client's feelings and let them know that they have the option to cancel the surgery if they are not comfortable with it. The nurse should also inform the provider and the surgical team about the client's situation and facilitate further discussion if needed.
Choice D reason: This is not the correct choice because this response is inappropriate and unethical. The nurse should not offer medication to the client to help them relax, as this may impair their decision-making capacity and consent. The nurse should not coerce or manipulate the client to undergo the surgery.
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