A nurse is planning to assign care activities to the assistive personnel (AP) on her team. Which of the following activities can the nurse assign to the AP? (Select all that apply.)
Check the position of a client in soft wrist restraints.
Accompany a client who has depression to occupational therapy.
Set limits with a client who has mania.
Sit with a client who has alcohol use disorder and whose last drink was five days ago.
Assess a client who has hypomania for exhaustion.
Correct Answer : A,B,D
Rationale:
A. Check the position of a client in soft wrist restraints is appropriate for an AP as it involves routine monitoring and ensuring the client's safety.
B. Accompany a client who has depression to occupational therapy is a task that can be assigned to an AP, as it involves providing support and ensuring the client's safe arrival to therapy.
C. Set limits with a client who has mania is not appropriate for an AP, as this involves therapeutic communication and behavior management, which requires nursing judgment.
D. Sit with a client who has alcohol use disorder and whose last drink was five days ago can be assigned to an AP as it involves providing a supportive presence and monitoring, but the nurse should assess for withdrawal symptoms.
E. Assess a client who has hypomania for exhaustion is a nursing responsibility that involves evaluation and judgment, making it inappropriate to delegate to an AP.
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Correct Answer is B
Explanation
Rationale:
A. Fill the bath basin with tap water that is 39° C (102.2° F) is too warm for bathing; the recommended water temperature is typically around 37°C (98.6°F) to prevent burns or discomfort.
B. Pull the curtain around the client's bed ensures privacy for the client during the bath, which is important for maintaining dignity and confidentiality.
C. Wash the client's arms and hands first is not necessarily the first step; typically, washing the face and then moving to the rest of the body is preferred.
D. Use a washcloth to wipe the client's eyes from the outer canthus to the inner canthus is incorrect as it should be done from the inner canthus to the outer canthus to avoid spreading any discharge across the eye.
Correct Answer is C
Explanation
Rationale:
A. Asking about discharge is a general inquiry that does not require immediate follow-up unless it’s related to specific discharge planning.
B. Changing the dressing is a routine postoperative care task and doesn’t necessarily require follow-up unless there’s a concern about the procedure.
C. Not receiving medications is a critical issue that needs immediate attention to address potential gaps in treatment.
D. Not knowing how to use the remote control is a minor issue that does not require clinical follow-up.