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 B
Explanation
Rationale:
A. Measuring I&O can be performed by an AP, as it does not require advanced skills or clinical judgment.
B. Reinforcing teaching about medication is within the LPN's scope of practice, as LPNs are trained to provide education and support based on the teaching provided by RNs or physicians.
C. Developing a plan of care is generally a responsibility of the RN, as it involves comprehensive assessment and planning.
D. Completing an admission assessment is a task for RNs due to its complexity and the need for a detailed clinical evaluation.
Correct Answer is C
Explanation
Rationale:
A. A client who is 4 days postpartum and has mastitis should be assessed, but this condition is less acute compared to the others.
B. A client who had a bilateral tubal ligation 12 hr previously requires post-operative monitoring, but this is less urgent than the client with an ectopic pregnancy.
C. A client admitted 1 hr ago for an ectopic pregnancy is the priority as this condition can be life-threatening and requires immediate assessment.
D. A client who is 1 day postpartum after a late-term miscarriage requires care, but the immediacy is less than that of the ectopic pregnancy client.