A nurse in an acute care setting is planning care for a group of clients at the beginning of the shift. Which of the following tasks should the nurse assign to the assistive personnel (AP)?
Removal of the nasogastric tube of a client who has been receiving enteral feedings
Monitoring vital signs of a client who had an appendectomy 12 hr ago
Application of antibiotic ointment to the arm of a client who has dermatitis
Obtaining medical history information from a stable client who is being admitted
The Correct Answer is B
Rationale:
A. Removal of the nasogastric tube is a more complex task that typically requires the nurse’s assessment and judgment.
B. Monitoring vital signs is within the scope of tasks that can be assigned to assistive personnel. This task involves routine observation and does not require complex decision-making.
C. Application of antibiotic ointment requires specific knowledge about the condition and treatment, which is generally performed by a nurse.
D. Obtaining medical history information is a task that requires clinical judgment and interaction, and should be done by a nurse rather than an assistive personnel.
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Correct Answer is C
Explanation
Rationale:
A. Opening a sterile tray flap toward the body can be incorrect practice, but it is a minor procedural issue that does not necessarily pose an immediate risk.
B. Using clean gloves is appropriate for non-sterile tasks like discontinuing an IV infusion.
C. Using a telephone number as identification is not acceptable; proper identification should include at least two identifiers like name and date of birth.
D. Emptying a colostomy pouch when it is one-third full is appropriate practice to prevent overflow and maintain hygiene.
Correct Answer is B
Explanation
Rationale:
A. "I want you to review the facility's policy on personal attire before you begin the shift." does not address the specific concern regarding infection risk related to artificial nails.
B. "There is a higher risk of infection for our clients associated with artificial nails." provides a clear and factual explanation of why artificial nails are not appropriate, focusing on client safety rather than personal appearance or policy.
C. "Why would you wear artificial nails to work when you know it's against the rules?" is confrontational and does not address the issue in a constructive manner.
D. "You should know that artificial nails have a very unprofessional appearance." focuses on appearance rather than the potential risk to clients' health.