Which of the following instructions provided by a nurse reflects effective communication regarding delegation of a task to an assistive personnel (AP)?

"Take vital signs every 2 hours for the client who had a cholecystectomy in room 6122.”

"Check the urinary output at 11:00 for John Doe and report it to me immediately.”

"Report to me if the chest tube drainage is excessive for Jane Doe in room 2438.”

"Please notify me of any clients whose vital signs or blood glucose levels are significant.”

Answer and Explanation

The Correct Answer is B

The answer is b. "Check the urinary output at 11:00 for John Doe and report it to me immediately.”

This instruction follows the five rights of delegation by including the requirements for right direction/communication: the data to collect, client-specific information, a timeline for data collection, and the expectation for communicating the findings back to the nurse.

a. "Take vital signs every 2 hours for the client who had a cholecystectomy in room 6122.” is wrong because it does not specify which client to monitor. The AP should know the client’s name and room number for identification and safety purposes.

c. "Report to me if the chest tube drainage is excessive for Jane Doe in room 2438.” is wrong because it does not define what constitutes excessive drainage. The nurse should provide clear and measurable criteria for the AP to follow.

d. "Please notify me of any clients whose vital signs or blood glucose levels are significant.” is wrong because it is vague and does not indicate which clients to check, how often to check them, or what values are significant. The nurse should provide specific and individualized instructions for each client

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Correct Answer is D

Explanation

Choice A rationale:

The National League for Nursing (NLN) focuses on nursing education standards and resources for nursing faculty. While it could provide useful insights, it's not the primary resource for policy creation related to procedures like catheter insertion.

Choice B rationale:

The American Academy of Nursing (AAN) is a professional organization that promotes leadership and education within nursing. While it might offer recommendations, it's not the primary resource for policy related to procedural changes in clinical settings.

Choice C rationale:

The Agency for Healthcare Research and Quality (AHRQ) is involved in research and quality improvement initiatives in healthcare. While it could provide evidence-based practices, it's not the primary source for policies specific to nursing procedures.

Choice D rationale:

The State Nurse Practice Act (NPA) outlines the scope of nursing practice within a particular state. It governs what nurses are allowed to do, including procedures like catheter insertion. The NPA ensures that nursing actions are within legal and regulatory bounds, making it the most relevant resource for creating a policy about catheter insertion.

A. The nurse places the sterile package with the top flap opening away from the body. B. The nurse pinches the flap on the inside of the package first to open it. C. The nurse reaches over the package to open the left flap. D. The nurse pulls the last flap of the package away from the body.

Correct Answer is A

Explanation

Choice A rationale:

Placing the sterile package with the top flap opening away from the body is the correct choice. This technique helps maintain the sterility of the contents by preventing potential contamination from the nurse's body and clothing.

Choice B rationale:

Pinching the flap on the inside of the package first to open it is not a recommended sterile technique. It could potentially introduce contamination from the nurse's hand into the sterile field when pinching the inner flap.

Choice C rationale:

Reaching over the package to open the left flap is not the ideal technique. Reaching over the sterile field can introduce the risk of contamination, as the nurse's arm and body might come into contact with the sterile supplies.

Choice D rationale:

Pulling the last flap of the package away from the body is not the most effective technique. This action could potentially lead to the nurse's hand coming close to or over the sterile field, increasing the risk of contamination.

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Which of the following instructions provided by a nurse reflects effective communication regarding delegation of a task to an assistive personnel (AP)?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is serving on a committee that is considering the creation of a policy that will allow nurses to insert peripherally inserted central catheters in the intensive care unit. Which of the following resources should the nurse consult in planning for this policy?

Correct Answer is D

Explanation

A charge nurse is observing a nurse perform a sterile dressing change for a client. Which of the following actions should the charge nurse identify as demonstrating sterile technique?

Correct Answer is A

Explanation

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