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 ["A","D","E"]
Explanation
Rationale:
A. While pulling the fire alarm is correct, removing the client from the room without following the full RACE sequence (Remove, Alarm, Confine, Extinguish/Evacuate) is incorrect. The immediate safety measures should include ensuring that the alarm is activated before evacuation and confining the fire if possible.
B. Verifying the order of protective equipment removal with the nurse shows a good practice and adherence to proper infection control procedures.
C. Washing hands prior to leaving the room after disinfecting equipment indicates proper infection control practice.
D. Handwashing is a crucial aspect of infection control. Failure to perform hand hygiene during or after patient care increases the risk of infection transmission. Immediate follow-up is needed to ensure that proper hand hygiene practices are adhered to.
E. Knowing the locations of alarms is vital for effective fire safety. Inability to identify these locations indicates a significant gap in preparedness for emergencies. Immediate follow-up is necessary to ensure that staff are familiar with fire safety procedures and equipment locations.
F. Successfully completing the skills in simulation, including emptying the client's trash can, shows adherence to task requirements but is not a critical issue requiring immediate follow-up compared to the other findings.