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","D"]
Explanation
Rationale:
A. Ambulate an older adult client who has hypertension is a task that an AP can perform, provided the client is stable and has been assessed by the nurse.
B. Provide discharge instructions for a client who has a new skin graft is a task that requires nursing judgment and cannot be delegated to an AP.
C. Check a blood product with another nurse prior to administration is a nursing responsibility that requires verification by licensed personnel and cannot be delegated to an AP.
D. Weigh a client who has heart failure is appropriate for an AP, as it involves routine measurement that can be delegated.
E. Perform an admission assessment on a client is a nursing responsibility and cannot be delegated to an AP.
Correct Answer is C
Explanation
Rationale:
A. False imprisonment involves restricting a person’s freedom of movement, not administering medication against their will.
B. Assault involves the threat of harm, not the actual administration of medication.
C. Battery is the intentional touching of another person without consent, which includes administering medication to a competent person who has refused it.
D. Negligence involves failure to meet the standard of care, but administering medication against a patient’s wishes is more accurately described as battery.