The following 4 questions pertain to this case study:
Which task is appropriate for the nurse to delegate to experienced certified nurse assistant (CNA)?
Monitor for shortness of breath or fatigue after ambulation.
Determine whether the patient is ready to increase activity.
Obtain the patient’s blood pressure and pulse rate after ambulation.
Instruct the patient on how to use an incentive spirometer.
The Correct Answer is C
Choice A reason:
Monitoring for shortness of breath or fatigue after ambulation is a critical task that requires clinical judgment and assessment skills. Certified Nurse Assistants (CNAs) are trained to assist with basic patient care activities but are not typically trained to assess and interpret clinical symptoms such as shortness of breath or fatigue. These symptoms could indicate serious complications such as pulmonary embolism or cardiac issues, which require immediate attention from a licensed nurse or physician. Therefore, this task is not appropriate for delegation to a CNA.
Choice B reason:
Determining whether the patient is ready to increase activity involves assessing the patient’s overall condition, including their vital signs, pain levels, and physical capabilities. This requires a comprehensive understanding of the patient’s medical history and current status, which falls within the scope of practice of a registered nurse (RN) or licensed practical nurse (LPN). CNAs do not have the training to make such determinations, as it involves critical thinking and clinical decision-making skills. Therefore, this task should not be delegated to a CNA.
Choice C reason:
Obtaining the patient’s blood pressure and pulse rate after ambulation is a task that is appropriate for delegation to a CNA. CNAs are trained to measure and record vital signs, including blood pressure and pulse rate. This task does not require clinical judgment or decision-making, making it suitable for delegation. The CNA can report the findings to the nurse, who can then interpret the results and make any necessary clinical decisions. This delegation allows the nurse to focus on more complex tasks that require their advanced training and expertise.
Choice D reason:
Instructing the patient on how to use an incentive spirometer involves patient education, which is a responsibility that typically falls to licensed nurses. Proper use of an incentive spirometer is crucial for preventing postoperative complications such as atelectasis and pneumonia. Ensuring that the patient understands how to use the device correctly requires not only demonstrating its use but also assessing the patient’s comprehension and ability to perform the task. This level of patient education and assessment is beyond the scope of practice for a CNA.
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Related Questions
Correct Answer is B
Explanation
Choice A reason:
Instructing the client to hold a pillow to the abdominal incision when coughing is a task that involves patient education and reinforcement of postoperative care techniques. While LPNs/LVNs can provide basic patient education, this specific task requires ensuring that the patient understands the importance of splinting the incision to reduce pain and prevent complications such as wound dehiscence. This level of instruction is typically within the scope of practice for a registered nurse (RN), who has more extensive training in patient education and postoperative care. Therefore, this task is not the most appropriate for delegation to an LPN/LVN.
Choice B reason:
Obtaining bedside blood glucose is a task that is appropriate for delegation to an LPN/LVN. LPNs/LVNs are trained to perform routine tasks such as monitoring vital signs, including blood glucose levels, especially in patients with diabetes. This task involves using a glucometer to measure the patient’s blood sugar levels and recording the results. It does not require complex clinical judgment, making it suitable for an LPN/LVN. Regular monitoring of blood glucose is crucial for managing diabetes and preventing complications such as hyperglycemia or hypoglycemia.
Choice C reason:
Creating the plan of care is a complex task that involves comprehensive assessment, critical thinking, and clinical judgment. This task is typically within the scope of practice for an RN, who is trained to develop and implement individualized care plans based on a thorough assessment of the patient’s needs, medical history, and current condition. The RN collaborates with other healthcare team members to ensure that the care plan addresses all aspects of the patient’s recovery and health maintenance. LPNs/LVNs can contribute to the care plan by providing input and performing delegated tasks, but they do not have the authority to create the plan of care independently.
Choice D reason:
Documenting postoperative teaching involves recording the education provided to the patient about their postoperative care, including instructions on medication, activity restrictions, wound care, and signs of complications to watch for. This task requires ensuring that the patient understands the information and can follow the instructions correctly. While LPNs/LVNs can reinforce teaching and provide basic education, the initial comprehensive teaching and documentation are typically the responsibility of an RN. The RN ensures that the teaching is thorough and that the patient has the necessary knowledge to manage their care at home.
Correct Answer is C
Explanation
Choice A: Hypotonic
A hypotonic solution has a lower concentration of solutes compared to the fluid inside the cells. When cells are placed in a hypotonic solution, water enters the cells, causing them to swell and potentially burst. This is because the osmotic pressure drives water into the cells to balance the solute concentration. Hypotonic solutions are not used to describe a state where extracellular and intracellular fluids have the same osmolality.
Choice B: Oncotic Pressure
Oncotic pressure, also known as colloid osmotic pressure, is the form of osmotic pressure exerted by proteins, primarily albumin, in the blood plasma. It plays a crucial role in maintaining fluid balance between the blood vessels and the surrounding tissues by pulling water into the circulatory system. Oncotic pressure is not related to the concept of equal osmolality between extracellular and intracellular fluids.
Choice C: Isotonic
An isotonic solution has the same concentration of solutes as the fluid inside the cells. When extracellular fluid is isotonic to intracellular fluid, there is no net movement of water into or out of the cells, maintaining cell stability. This balance is crucial for normal cellular function and is the term used to describe equal osmolality between extracellular and intracellular fluids.
Choice D: Hypertonic
A hypertonic solution has a higher concentration of solutes compared to the fluid inside the cells. When cells are placed in a hypertonic solution, water leaves the cells, causing them to shrink or crenate. This occurs because the osmotic pressure drives water out of the cells to balance the solute concentration. Hypertonic solutions are not used to describe a state where extracellular and intracellular fluids have the same osmolality.
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