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 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.
Correct Answer is A
Explanation
Rationale:
A. An infant who has pertussis and is receiving oxygen via nasal cannula requires immediate assessment to ensure that the oxygen therapy is adequate and to monitor for any signs of respiratory distress or worsening condition.
B. An adolescent who was admitted to the unit in sickle cell crisis and is ready for discharge instructions does not require immediate assessment as the client is stable enough for discharge planning.
C. A school-age child who has diabetes mellitus and requires blood glucose monitoring should be assessed, but it is less urgent compared to a client with a respiratory condition.
D. A toddler who has both arms in casts and needs to be fed his breakfast needs attention, but this is less critical compared to monitoring a client with a respiratory condition.