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 D
Explanation
Rationale:
A. A client who reports pain as 4 on a scale of 1 to 10 at 0800 now reports pain as 6 needs pain management, but this is less urgent compared to potential signs of hypotension.
B. A client whose wound drainage at 0800 was sanguineous and now it is serosanguineous indicates normal progression of wound healing; thus, it is less critical.
C. A client who has a prescription for insulin and his premeal capillary blood glucose was 110 mg/dL and his post-meal capillary blood glucose is now 160 mg/dL needs blood glucose management, but this is less urgent than assessing for potential hypovolemia or shock.
D. A client whose blood pressure at 0800 was 138/86 mm Hg and at 1200 is 106/60 mm Hg is experiencing a significant drop in blood pressure, which could indicate hypovolemia or shock. This requires immediate assessment and intervention to prevent complications.
Correct Answer is A
Explanation
Rationale:
A. "The client must provide permission to share the records with you." is the correct procedure as medical records are confidential and require patient consent for release to family members.
B. I will ask the nursing supervisor to obtain the medical records for you is not correct unless the client has given permission.
C. The health care provider will share this information with you does not address the need for patient consent.
D. The ethics committee will need to approve this request for you is not apptlicable; consent from the client is required.