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.”
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.”
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
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
Providing the client with information about advance directives is an appropriate intervention. Advance directives are legal documents that allow individuals to communicate their preferences for medical treatment in the event they become unable to make decisions for themselves. Educating the client about the importance and benefits of advance directives empowers them to make informed decisions about their care.
Choice B rationale:
Encouraging the client to contact an attorney to create advance directives is not the primary responsibility of the hospice nurse. While legal assistance might be helpful, the nurse should first ensure that the client understands the concept of advance directives and their significance before suggesting legal involvement.
Choice C rationale:
Informing the client that they will need a relative to witness their advance directives is not accurate. While witnesses are often required when signing legal documents, the specific requirements for advance directives can vary by jurisdiction. It's important for the nurse to provide accurate information and not make assumptions about legal processes.
Choice D rationale:
Telling the client that The Joint Commission requires clients to have advance directives is not accurate. While The Joint Commission emphasizes the importance of patient rights and informed decision-making, it does not mandate that all clients must have advance directives. The decision to create advance directives is a personal choice and should be based on the individual's values and preferences.
Correct Answer is C
Explanation
Choice A rationale:
The nurse should not promise that a social worker will address the client's concerns, as this might not be accurate. While a social worker could be involved in the client's care, it's not their sole responsibility to address all concerns. The primary role of a social worker might be to provide emotional support and assistance with psychosocial issues.
Choice B rationale:
Suggesting that the client should plan to go to a skilled nursing facility after discharge might not be appropriate unless it's medically necessary. Terminal illness often requires a focus on palliative and hospice care rather than transferring to another care facility.
Choice C rationale:
This is the correct choice. The case manager plays a key role in coordinating the various resources and services the client will need after discharge. They ensure a smooth transition from the hospital to home, including arranging for home health care, medical equipment, and any other necessary services.
Choice D rationale:
Telling the client that they will need hospice care until they feel stronger is not appropriate. Hospice care is specifically for individuals with terminal illnesses who have a limited life expectancy. It is not about getting stronger but about providing comfort and support during the end-of-life period.
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