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 ["A","B","C"]
Explanation
Rationale:
A. Verify the client understands the surgical procedure ensures the client is making an informed decision based on a clear understanding of the procedure, risks, and benefits.
B. Validate the signature is authentic is crucial to confirm that the consent form is genuinely signed by the client, indicating their agreement to proceed
.
C. Confirm that the consent is voluntary ensures that the client is not coerced into giving consent, upholding the principle of autonomy.
D. Explain the surgical procedure to the client is the responsibility of the surgeon or the provider, not the nurse. The nurse’s role is to witness the consent process and ensure that the client has been provided with and understands the information.
E. Establishing that the client is able to pay is not related to the informed consent process. Financial aspects are handled separately from the consent for treatment.
Correct Answer is C
Explanation
Rationale:
A. A client who is alert and oriented makes an informed decision to leave the hospital against medical advice. The nurse applies restraints to the client to prevent him from leaving constitutes a violation of patient autonomy and could be considered false imprisonment rather than negligence.
B. A nurse identifies the absence of peripheral pulsation in a casted extremity in the early morning and reports it to the provider in the early afternoon might be considered a delay in care but does not necessarily meet the criteria for negligence unless it leads to harm.
C. A client who is competent refuses an antidepressant medication. The nurse dissolves the medication in food and administers it to her without her knowledge is an example of negligence as it violates the client’s autonomy and informed consent.
D. A nurse finds a client who is on a low-sodium diet eating salted potato chips. The nurse tells the client that she will apply wrist restraints if he does not stop eating the potato chips is inappropriate but does not specifically represent negligence; it’s more about improper behavior or coercion.