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Which action can a nurse delegate to AP?

A.

Performing glucose monitoring every 6 hours on a stable patient

B.

Teaching the patient about the need for enteral feeding

C.

Administering enteral feeding bolus after tube placement has been verified

D.

Evaluating the patient’s tolerance of the enteral feeding

Answer and Explanation

The Correct Answer is A

Delegation is guided by the “Five Rights of Delegation” (right task, circumstance, person, direction, and supervision). In general, APs (assistive personnel) can perform routine, stable, non-invasive tasks.

Rationale for correct answer:

1. Performing glucose monitoring every 6 hours on a stable patient: APs may be trained and delegated to perform point-of-care blood glucose monitoring in stable clients because it is a standardized procedure, and the nurse interprets and acts on the results.

 

Rationale for incorrect answers:

2. Teaching the patient about the need for enteral feeding: Teaching requires professional nursing knowledge, critical thinking, and individualized instruction. Cannot be delegated to AP.

3. Administering enteral feeding bolus after tube placement has been verified: Feeding via tube involves risk of aspiration and requires assessment and verification skills, which cannot be delegated.

4. Evaluating the patient’s tolerance of the enteral feeding: Evaluation is part of the nursing process (assessment and judgment) and cannot be delegated to AP.

 

Take home points:

  • APs can perform stable, routine, non-invasive tasks (e.g., vital signs, I&O, ADLs, glucose checks in stable clients).
  • The nurse retains responsibility for tasks involving teaching, assessment, critical judgment, and evaluation


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Related Questions

Correct Answer is B

Explanation

Safe placement of a small-bore nasally placed feeding tube (Dobhoff tube or similar) is crucial for effective nutrition delivery and to prevent complications such as aspiration pneumonia.

Rationale for correct answer:

2. The stomach is the most common site for small-bore nasogastric feeding tube placement. It allows for bolus or continuous feeding, easy monitoring, and is the safest initial site. Placement is verified by X-ray before feeding begins.

Rationale for incorrect answers:

1. The esophagus is the passageway from the throat to the stomach. If a feeding tube tip remains here, formula could easily reflux into the airway and cause aspiration.

3. Feeding tubes are not advanced into the large intestine. The large bowel’s function is fluid absorption and stool formation, not nutrient absorption.

4. In some cases, feeding tubes are advanced past the stomach into the duodenum or jejunum, especially for patients at high risk of aspiration (e.g., impaired gastric emptying, severe reflux). While this is appropriate, it requires specialized placement.

Take home points:

  • Small-bore nasogastric feeding tubes are most commonly placed in the stomach.
  • Placement in the small intestine (jejunum/duodenum) is used for patients at high aspiration risk, but never in the esophagus or large intestine.

Correct Answer is C,F,A,H,D,G,B,E

Explanation

Point-of-care blood glucose monitoring must combine infection control, correct technique, and device accuracy. Steps done in the right order reduce false readings and prevent transmission of infection.

Rationale for correct answer:

  1. (3) Instruct patient to perform hand hygiene with soap and water.
    Prevents contamination from sugar or other residues on the fingers, which could give falsely high readings.
  2. (6) Check code on test strip vial.
    Ensures the test strips are calibrated correctly for the glucometer.
  3. (1) Press button on meter to confirm match codes.
    Confirms that the meter’s internal code matches the strip code for accuracy.
  4. (8) Perform hand hygiene and put on clean gloves.
    Protects both nurse and patient from bloodborne pathogens and infection transmission.
  5. (4) Clean patient finger with antiseptic swab.
    Disinfects the puncture site. Important: allow to dry to avoid dilution of blood with alcohol.
  6. (7) Holding lancet to finger, press release button on machine.
    Obtains capillary blood sample safely and effectively.
  7. (2) Bringing meter to test strip, allow blood drop to wick onto test strip.
    Ensures an adequate sample is absorbed by the strip for analysis.
  8. (5) Interpret results and document.
    Completes the procedure and ensures accurate communication of results for clinical decision-making.

Take home points:

  • Correct sequence matters: code verification comes before gloves and antiseptic.
  • Always finish with interpretation and documentation- this closes the loop on safe patient care.

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