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 B
Explanation
Rationale:
A. "It is time to sign the consent so your treatment can begin." dismisses the client's valid question about alternative options and does not address their concern.
B. "Have you discussed other treatments with your provider?" is an appropriate response as it encourages the client to seek information about alternatives from their healthcare provider, who can offer comprehensive options and explanations.
C. "I can inform the surgeon you do not want the surgery." does not address the client's question about alternatives and assumes the client’s decision without further discussion.
D. "I would not have this type of surgery if I were you." is a personal opinion and is not appropriate for a nurse to provide, as it is not based on the client’s individual medical needs or informed consent principles.
Correct Answer is C
Explanation
Rationale:
A. A client who has pneumonia and has an axillary temperature of 38° C (101° F) has an elevated temperature, but it is less critical than immediate concerns with circulation.
B. A client who has diarrhea and requests clear liquids for breakfast needs dietary adjustments but does not present as urgent.
C. A client who has a cast on the left leg and reports numbness and paresthesia could be experiencing complications such as compartment syndrome, which is an urgent condition requiring immediate assessment.
D. A client who has type 1 diabetes mellitus and has a fasting blood glucose level of 150 is important to monitor but not as immediately critical as potential complications with circulation.