A nurse on a medical unit is making staff assignments. Which of the following tasks should the nurse delegate to an assistive personnel?
Inserting a straight urinary catheter for a client
Performing perineal care for a client who has an indwelling urinary catheter
Showing a client how to use an incentive spirometer
Increasing oxygen flow for a client who has a nasal cannula
The Correct Answer is B
A. Inserting a straight urinary catheter for a client:
Inserting a urinary catheter involves a sterile procedure and requires the specialized skills of a licensed nurse. This task should not be delegated to assistive personnel.
B. Performing perineal care for a client who has an indwelling urinary catheter.
Delegating tasks should align with the education, training, and scope of practice of the assistive personnel. Performing perineal care for a client with an indwelling urinary catheter is a task that can be appropriately delegated to assistive personnel. This task involves basic hygiene and does not require the advanced skills or knowledge of a licensed nurse.
C. Showing a client how to use an incentive spirometer:
Educational tasks, such as demonstrating how to use an incentive spirometer, require knowledge and understanding of the device, as well as the ability to assess and respond to the client's needs. This task is best performed by a licensed nurse.
D. Increasing oxygen flow for a client who has a nasal cannula:
Adjusting oxygen flow involves assessing the client's condition and making decisions based on the client's oxygenation needs. This task requires the clinical judgment of a licensed nurse and should not be delegated to assistive personnel.
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Related Questions
Correct Answer is C
Explanation
A. "The surgeon can obtain informed consent from the client's adult cousin."Informed consent must be obtained from a parent or legal guardian for a minor. An adult cousin does not have the legal authority to provide consent unless they are the legal guardian of the minor, which is not indicated in this scenario.
B. "The surgeon should delay surgery until he can obtain informed consent from a parent."Delaying surgery in an emergency situation could endanger the client's life or health. In such cases, waiting for parental consent is not advisable, and other legal mechanisms, such as implied consent, should be used to proceed with necessary treatment.
C. "The surgeon can proceed with the surgery by invoking implied consent."In emergency situations where the client is a minor and the parents or legal guardians are not available to provide consent, the principle of implied consent allows healthcare providers to perform life-saving procedures without explicit consent. The law recognizes that in emergencies, delaying treatment to obtain consent could result in harm, so the surgeon can proceed with the surgery.
D. "The client's pediatrician can obtain implied consent."The concept of implied consent is not something that can be "obtained" by another healthcare provider. It is a legal principle that allows healthcare providers to act in the best interest of the client during an emergency when consent cannot be obtained. The pediatrician does not have a role in obtaining or invoking implied consent in this context; it is the responsibility of the surgeon performing the emergency procedure.
Correct Answer is A
Explanation
A. The client's blood pressure was recorded at 0730 and 1130.
In a change-of-shift report, it is important to communicate vital signs, especially changes in the client's condition. Recording the blood pressure at different times during the shift helps the oncoming nurse understand the client's cardiovascular status and identify trends or potential issues.
B. The client's pain medication was administered twice during this shift:
While medication administration is important information, specifying the number of times pain medication was administered may be less relevant in a brief change-of-shift report. It's more critical to communicate the client's pain level, response to medication, or any concerns related to pain management.
C. The client's enteral feeding bag needs to be changed at 2200:
While enteral feeding is an essential aspect of care, the timing of the feeding bag change may not be as crucial in a change-of-shift report. Instead, it would be more pertinent to communicate any issues related to the client's tolerance of feeding, any changes in feeding rate, or signs of intolerance.
D. The client received a bath and backrub:
Personal care activities, such as a bath and backrub, are essential components of nursing care, but they may be less critical in a change-of-shift report unless there are specific concerns related to the client's skin condition or overall well-being. More emphasis should be placed on clinical assessments and changes in the client's condition.
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