A nurse is delegating client care assignments for the shift. Which of the following tasks should the nurse delegate to an assistive personnel (AP)?
Teach a client about low-sodium foods.
Measure and record intake and output for a client.
Perform wound irrigation for a client.
Evaluate pain relief for a client following the administration of a pain medication.
The Correct Answer is B
Rationale
A. Teaching about low-sodium foods requires specialized knowledge and should be performed by an RN.
B. Measuring and recording intake and output can be done by an AP, as it involves routine data collection rather than clinical judgment.
C. Wound irrigation is a more complex procedure that requires clinical skills and should be performed by an RN or LPN.
D. Evaluating pain relief involves clinical assessment and judgment, which is beyond the scope of an AP.
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Correct Answer is A
Explanation
Rationale:
A. Diaphoretic with epigastric pain could be indicative of a myocardial infarction or other severe condition and requires immediate attention.
B. A toddler with a laceration and distress needs care but is not as urgent as potential cardiac issues.
C. An adolescent with slurred speech and belligerence could indicate a neurological issue, but is less immediate than a potential cardiac event.
D. A young adult with a sunburn is painful but not life-threatening compared to other scenarios.
Correct Answer is D
Explanation
Rationale:
A. The nurse coats the indwelling urinary catheter with lubricant is correct and necessary for the procedure to reduce discomfort and facilitate insertion.
B. The nurse applies the sterile drape prior to inserting the urinary catheter is a proper step to maintain a sterile field during the procedure.
C. The nurse provides perineal care prior to inserting the urinary catheter is appropriate as it ensures cleanliness before catheter insertion.
D. The nurse separates the client's labia with her dominant hand should not be done; the non-dominant hand should be used to hold the labia apart to maintain sterility.