Which term will the nurse use to document the patient’s age-related hearing loss?

Choice A reason: This is incorrect. Documenting the finding in the patient’s medical record is an important step, but not the most appropriate first action of the nurse. The nurse should first confirm the irregularity by counting the apical pulse.

Choice B reason: This is incorrect. Assessing the brachial pulse for a pulse deficit is a useful technique, but not the most appropriate first action of the nurse. A pulse deficit is the difference between the apical and radial pulse rates. The nurse should first count the apical pulse before comparing it with the radial pulse.

Choice C reason: This is incorrect. Notifying the health care provider immediately is a necessary step, but not the most appropriate first action of the nurse. The nurse should first gather more information by counting the apical pulse and determining the type and severity of the irregularity.

Choice D reason: This is correct. Counting the patient’s apical pulse for one full minute is the most appropriate first action of the nurse. The apical pulse is the most accurate way to measure the heart rate and rhythm. The nurse should listen to the heart sounds at the apex of the heart, which is located at the fifth intercostal space, left midclavicular line. The nurse should count the number of beats and note any irregularities, such as skipped, extra, or uneven beats..

Choice A reason: This is the correct choice because the nurse checks if the hospital policy allows the licensed practical nurse to perform venipuncture before delegating the task is an action that demonstrates the concept of right supervision. Right supervision is one of the five rights of delegation, which are the principles that guide the nurse to delegate tasks safely and effectively. Right supervision means that the nurse provides appropriate guidance and monitoring of the delegated task and evaluates the outcomes³. By checking the hospital policy, the nurse ensures that the task is within the scope of practice and competency of the licensed practical nurse and that the delegation is consistent with the standards of care.

Choice B reason: This is an incorrect choice because the nurse confirms that the patient’s urine output is entered into the medical record by the nursing assistant by the end of the shift is not an action that demonstrates the concept of right supervision. Right supervision is one of the five rights of delegation, which are the principles that guide the nurse to delegate tasks safely and effectively. Right supervision means that the nurse provides appropriate guidance and monitoring of the delegated task and evaluates the outcomes³. By confirming the documentation, the nurse is performing a quality check, but not providing supervision of the delegated task.

Choice C reason: This is an incorrect choice because the nurse ensures that the scale is accurate before directing the nursing assistant to obtain the patient’s weight is not an action that demonstrates the concept of right supervision. Right supervision is one of the five rights of delegation, which are the principles that guide the nurse to delegate tasks safely and effectively. Right supervision means that the nurse provides appropriate guidance and monitoring of the delegated task and evaluates the outcomes³. By ensuring the accuracy of the scale, the nurse is preparing the equipment, but not providing supervision of the delegated task.

Choice D reason: This is an incorrect choice because the nurse directs the nursing assistant to ambulate the patient at least 20 feet in the hallway using the gait belt before lunch is not an action that demonstrates the concept of right supervision. Right supervision is one of the five rights of delegation, which are the principles that guide the nurse to delegate tasks safely and effectively. Right supervision means that the nurse provides appropriate guidance and monitoring of the delegated task and evaluates the outcomes³. By directing the nursing assistant, the nurse is assigning the task, but not providing supervision of the delegated task.