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. Assessment includes the current status and vital signs of the client, which are part of the information the nurse provides to assess the client’s condition.
B. Situation describes the problem or concern that prompted the communication, not detailed vital signs.
C. Background provides context or history relevant to the situation but does not include current vital signs.
D. Recommendation involves suggesting actions or solutions but does not include the current condition details.
Correct Answer is D
Explanation
Rationale:
A. A red rash is concerning but not typically an immediate life-threatening condition compared to other options.
B. Severe flank pain may indicate a serious condition but is not as immediately critical as a life-threatening injury.
C. Multiple fractures can be serious but are generally less urgent compared to critical injuries involving major arteries.
D. A punctured femoral artery is a life-threatening emergency requiring immediate intervention to prevent massive blood loss and ensure survival.