A nurse is caring for four clients and is delegating tasks to an assistive personnel (AP). Which of the following tasks should the nurse plan to have the AP perform?
Provide postmortem care for a client who died 1 hr ago.
Reinforce discharge instructions with a client who is 2 days postoperative following an appendectomy.
Interpret deviations in a client's vital signs.
Insert an NG tube for a client who has difficulty eating.
The Correct Answer is A
A. Providing postmortem care is a task that can be delegated to assistive personnel, as it involves following established protocols and does not require clinical judgment.
B. Reinforcing discharge instructions requires clinical knowledge and assessment, making it inappropriate for delegation to an AP.
C. Interpreting deviations in a client's vital signs necessitates nursing judgment and clinical expertise, which an AP does not possess.
D. Inserting an NG tube is a skilled nursing procedure that requires assessment and decision-making, thus it should not be delegated to an AP.
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Correct Answer is D
Explanation
A. While paranoia in a client with dementia can be concerning, it is not immediately life-threatening and may require additional support or medication adjustments.
B. Itching after receiving a dose of cefaclor may indicate an allergic reaction, but further assessment would be needed to determine the severity.
C. A weight gain of 1 kg (2.2 lb) in a client with heart failure should be monitored, but it is not an immediate concern unless accompanied by other symptoms of fluid overload.
D. The progression of a pressure ulcer from stage II to stage III indicates a worsening condition that requires urgent intervention to prevent further complications and potential infection, making it the highest priority to report.
Correct Answer is D
Explanation
A. While it's a good idea to rotate nonperishable food items to ensure freshness, the recommendation is typically to check them periodically rather than replace them annually, making this statement less accurate for disaster preparedness.
B. Having a backup supply of nonprescription medications is beneficial, but this is not a primary recommendation for disaster preparedness and may not specifically apply to all older adults.
C. The standard recommendation is to stock at least 1 gallon of water per person per day, not 2 liters, which is less than the recommended amount for hydration and other needs during emergencies.
D. Gathering enough supplies to last for 2 weeks is an essential component of disaster preparedness, especially for older adults who may have specific health needs and may not have easy access to supplies during a disaster.