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 A
Explanation
A. Raisin toast is a bland carbohydrate that is generally well-tolerated and can help settle the stomach, making it a suitable choice for clients experiencing chemotherapy-induced nausea.
B. Soft-serve ice cream may be too rich and can upset the stomach for some clients undergoing chemotherapy, leading to increased nausea.
C. String cheese is high in fat and protein, which might not be well-tolerated during episodes of nausea, as heavy foods can exacerbate discomfort.
D. Hot tea may be soothing for some clients; however, certain herbal teas can sometimes provoke nausea or have an adverse effect, making it less ideal than bland carbohydrates.
Correct Answer is A
Explanation
A. Reporting the incident to the manager of the pharmacy is the appropriate action to ensure that the medication error is addressed and investigated properly, as this can help prevent future occurrences.
B. Incident reports should not be placed in the client's medical record, as they are separate documents meant for internal review and quality improvement.
C. Documenting the doubled dose in the client's medical record does not fulfill the legal requirements for reporting medication errors and could mislead future care providers about the medication administration history.
D. Contacting the nurse from the previous shift may be necessary for understanding the situation, but the priority is to report the incident properly to ensure patient safety.