A nurse on a medical-surgical unit is making staff assignments. Which of the following tasks should the nurse delegate to an assistive personnel?
Pouching a client's established ostomy
Demonstrating the use of an incentive spirometer to a client
Reinforcing teaching with a client about a low-sodium diet
Updating a family member about a client's condition
The Correct Answer is A
Rationale:
A. Pouching a client’s established ostomy is within the scope of practice for assistive personnel (AP) if the client’s stoma is stable and the procedure is routine. This task is considered basic care and does not require independent nursing judgment, making it appropriate to delegate.
B. Demonstrating the use of an incentive spirometer requires teaching skills and assessment of the client’s understanding, which falls under the nurse’s professional responsibilities. APs may reinforce instructions but should not provide initial teaching or assess competency.
C. Reinforcing teaching about a low-sodium diet involves patient education and monitoring understanding, which requires nursing judgment. The nurse cannot delegate initial teaching or evaluation of understanding to APs.
D. Updating a family member about a client’s condition involves interpreting clinical information and making judgments about what to communicate. This responsibility cannot be delegated to APs, as it falls within the nurse’s professional scope and is protected under HIPAA and facility policies.
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Related Questions
Correct Answer is D
Explanation
Rationale:
A. Measuring the size of a wound requires clinical judgment to accurately assess depth, length, width, and tissue characteristics. This task is within the registered nurse’s scope of practice and should not be delegated to an AP.
B. Collecting a wound culture is an invasive procedure that requires aseptic technique and clinical judgment to ensure accurate results and prevent infection. This task cannot be delegated to an AP.
C. Asking the client to describe their pain level involves assessment and documentation that requires nursing knowledge and judgment. The nurse must interpret the pain information and determine interventions.
D. Transporting the client for wound debridement is a non-invasive, routine task that does not require clinical judgment. An AP can safely assist the client in moving from the unit to the procedure area, ensuring mobility support and safety.
Correct Answer is D
Explanation
Rationale:
A. Toxoplasmosis is typically not a nationally notifiable disease in most states unless it is part of a specific outbreak or associated with congenital infections. Routine cases are generally managed by the healthcare provider and reported at the local level if required.
B. Candida infections are usually common and opportunistic, not reportable to the CDC unless part of an outbreak investigation.
C. Systemic lupus erythematosus (SLE) is an autoimmune condition and not considered a reportable disease. Reporting is not required for routine surveillance.
D. Lyme disease is a nationally notifiable disease. The CDC requires reporting of confirmed and probable cases to monitor epidemiological trends, identify outbreaks, and implement public health interventions. Reporting helps track geographic distribution and incidence of tick-borne illnesses.
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