The nurse is reassessing a 57-year-old female client who was admitted to the hospital with a left upper arm open wound infection (methicillin-resistant Staphylococcus aureus [MRSA] and several gram-negative bacteria) and cellulitis 5 days ago.

Tomorrow she is scheduled for discharge to home with her daughter to continue oral antibiotic therapy for another 10 days.

For each assessment finding, use the choices from the drop-down box to indicate whether the interventions were Effective (helped to meet expected outcomes), Ineffective (did not help to meet expected outcomes), or Unrelated (not related to the expected outcomes).

Choice A rationale
The RN must ensure that the nurse aide has the required training to perform these tasks. This is because the RN is responsible for determining client needs and when to delegate. The RN must also ensure that the delegate is competent to perform the activity.
Choice B rationale
The RN must maintain accountability for ensuring the delegated tasks are conducted correctly and completely. This is because the RN is answerable for their own choices, decisions, and actions as measured against a standard.
Choice C rationale
The RN must ensure policies cover the delegation. This is because the RN must understand the delegation process and the state nurse practice act (NPA) to ensure that it is safely, ethically, and effectively carried out.
Choice D rationale
The RN must perform an assessment of the patient prior to delegation. This is because the RN’s decision of whether or not to delegate is based upon their judgement concerning the condition of the patient.
Choice E rationale
While observing all tasks performed by the nurse aide II is a good practice, it is not a requirement for the RN in regard to this delegated task.

Choice A rationale
While trust is an important aspect of the patient-family relationship, it’s not the primary need being considered in this scenario. The nurse is discussing allowing patient families to visit as often as the patient’s condition will allow. This is more about providing emotional and social support to the patient, rather than building trust.
Choice B rationale
Social support is the primary need being considered in these conversations. Evidence shows that the unrestricted presence and participation of a support person (i.e., family as defined by the patient) can improve the safety of care and enhance patient and family satisfaction. This is especially true in the ICU, where patients are often unable to speak for themselves.
Choice C rationale
While environmental considerations are important in any care setting, they’re not the primary need being considered in this scenario. The nurse is discussing the frequency of family visits, which is more about providing social support to the patient.
Choice D rationale
Dependence is not the primary need being considered in this scenario. The nurse is discussing the frequency of family visits, which is more about providing social support to the patient.
While patients in the ICU may be dependent on medical staff for their physical needs, the presence of family can provide emotional and social support.