A nurse on a medical-surgical unit is preparing to assign vital sign measurements for a group of clients. Which of the following clients should the nurse delegate to an assistive personnel?

A client who has sickle-cell anemia and is requesting water

A client who has just returned to the unit from the PACU

A client who reports acute chest pain

A client who has a closed head injury and increased intracranial pressure

Answer and Explanation

The Correct Answer is A

Rationale:

A. A client who has sickle-cell anemia and is requesting water is stable and does not have acute complications at this moment. Measuring vital signs and providing oral fluids are within the scope of practice of an assistive personnel (AP). The AP can safely perform these routine tasks under the nurse’s supervision.

B. A client who has just returned from the PACU requires frequent monitoring, assessment for postoperative complications, and nursing judgment. Vital signs in this case may indicate instability, so an RN must perform the assessment.

C. A client reporting acute chest pain requires immediate assessment, intervention, and possible activation of emergency protocols. Delegating vital signs to an AP would delay urgent care.

D. A client with a closed head injury and increased intracranial pressure is at high risk for rapid deterioration. Vital signs and neurological assessments require nursing judgment and continuous monitoring, so an AP cannot safely perform these assessments.

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Correct Answer is A

Explanation

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.

A. An adolescent client who has an injured ankle and reports a pain level of 8 on a scale from 0 to 10 B. An older adult client who has dyspnea and a respiratory rate of 26/min C. A toddler who has a 2 cm (0.79 in) head laceration oozing dark red blood D. An adult client who has large ecchymoses on both legs

Correct Answer is B

Explanation

Rationale:
A. An injured ankle with severe pain is important to assess for fractures or soft tissue injury, but it is not immediately life-threatening. This client can safely wait after more urgent cases are addressed.

B. An older adult with dyspnea and a respiratory rate of 26/min is showing signs of respiratory compromise. Airway and breathing problems are life-threatening and take priority according to the ABC (Airway, Breathing, Circulation) framework. Prompt assessment and intervention are required to prevent deterioration.

C. A toddler with a small head laceration that is oozing dark red blood requires attention, but the amount of bleeding described is not severe enough to be immediately life-threatening. The wound can be treated after more urgent respiratory concerns are addressed.

D. An adult with large ecchymoses on both legs may have a bleeding or clotting disorder, but without signs of active bleeding, airway compromise, or hemodynamic instability, this is less urgent than respiratory distress.

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A nurse on a medical-surgical unit is preparing to assign vital sign measurements for a group of clients. Which of the following clients should the nurse delegate to an assistive personnel?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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