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. Call the provider for a stat DNR order is not appropriate as the client is already in a critical state requiring immediate action.
B. Call the emergency response team is necessary as the client is pulseless, and resuscitation should be initiated according to standard procedures until a DNR order is confirmed.
C. Seek immediate help from the risk manager is not appropriate at this moment; the immediate concern is the client's emergency situation.
D. Respect the family's wishes and do nothing is not appropriate as immediate life-saving measures should be taken until a formal DNR order is in place.
Correct Answer is B
Explanation
Rationale:
A. Reinforcing discharge teaching is less critical during a disaster and should be secondary to addressing immediate needs.
B. Focusing on life-threatening emergencies aligns with the priorities in a disaster situation, where resources are limited.
C. Stocking additional supplies should be managed based on current needs and priorities but is not as urgent as immediate patient care.
D. Focusing on ADLs is important but not the priority when dealing with life-threatening situations.