A nurse is planning client care for herself and an assistive personnel (AP) working with her. Which of the following tasks should the nurse plan to perform?
Assisting a client to cough and deep breathe
Application of antiembolic stockings
Administration of an enema
Assessing a client's sacrum for edema
The Correct Answer is D
Rationale:
A. Assisting a client to cough and deep breathe is a task that can be performed by an AP under supervision.
B. Application of antiembolic stockings is within the scope of APs, though it may be monitored by an RN.
C. Administration of an enema typically requires nursing judgment and assessment, making it more appropriate for the RN.
D. Assessing a client’s sacrum for edema requires clinical assessment skills and nursing judgment, which should be performed by an RN.
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Correct Answer is A
Explanation
Rationale:
A. Performing blood glucose monitoring before breakfast is crucial for timely insulin administration and managing diabetes effectively.
B. Applying a condom catheter is important but can generally be done after more urgent tasks.
C. Delivering a clean urine specimen is important but less time-sensitive compared to blood glucose monitoring.
D. Feeding a client is important but may not be as urgent as tasks directly affecting medical management.
Correct Answer is B
Explanation
Rationale:
A. The nurse does not relinquish accountability when delegating tasks to an AP; the nurse remains responsible for the overall care and outcomes.
B. Considering the AP's level of experience is crucial for effective delegation to ensure that tasks are matched to the AP's skills and knowledge.
C. Providing client education is generally beyond the scope of AP duties and should be performed by a licensed nurse.
D. Re-delegating tasks is not allowed; the original delegator remains responsible for ensuring the task is completed properly and should delegate directly to the appropriate individual.