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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Rationale:
A. Assigning a client to a room with positive airflow is used for protective isolation to protect immunocompromised clients, not for droplet precautions. Influenza requires containment of respiratory droplets, not room airflow for protection.
B. Wearing a surgical mask within 3 feet of the client is correct for droplet precautions. Influenza is transmitted via large respiratory droplets, which typically travel short distances (about 3–6 feet). The surgical mask protects the nurse from inhaling droplets during close contact.
C. An N95 respirator is used for airborne precautions, such as with tuberculosis or measles, where infectious particles are smaller and can remain suspended in the air. Influenza does not require an N95 respirator unless aerosol-generating procedures are performed.
D. A room with a high-efficiency particulate air (HEPA) filtration system is part of airborne isolation to remove smaller particles from the air. This is not necessary for standard droplet precautions, as influenza primarily spreads through larger droplets.
Correct Answer is B
Explanation
Rationale:
A. Coordinating care is part of the nurse’s responsibilities, but it is not the primary role of advocacy. Advocacy focuses on supporting clients’ rights, preferences, and informed decision-making rather than assuming full responsibility for care coordination.
B. Empowering clients to make informed health care decisions is the essence of nursing advocacy. The nurse provides information, clarifies options, and supports the client in expressing their preferences and making decisions that align with their values and goals. This ensures respect for client autonomy.
C. Suggesting the “best” course of action for indecisive clients undermines their autonomy and is not consistent with advocacy. Advocacy means guiding and supporting, not making decisions on behalf of the client unless they lack decisional capacity.
D. Adhering strictly to the provider’s prescribed treatments is part of nursing care but does not reflect advocacy, which may involve questioning or clarifying orders if they conflict with the client’s wishes or best interests.
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