A nurse is planning to assign tasks for a group of clients. Which of the following tasks should the nurse plan to assign to an assistive personnel (AP)? (Select all that apply.)
Ambulate an older adult client who has hypertension.
Provide discharge instructions for a client who has a new skin graft.
Check a blood product with another nurse prior to administration.
Weigh a client who has heart failure.
Perform an admission assessment on a client.
Correct Answer : A,D
Rationale:
A. Ambulate an older adult client who has hypertension is a task that an AP can perform, provided the client is stable and has been assessed by the nurse.
B. Provide discharge instructions for a client who has a new skin graft is a task that requires nursing judgment and cannot be delegated to an AP.
C. Check a blood product with another nurse prior to administration is a nursing responsibility that requires verification by licensed personnel and cannot be delegated to an AP.
D. Weigh a client who has heart failure is appropriate for an AP, as it involves routine measurement that can be delegated.
E. Perform an admission assessment on a client is a nursing responsibility and cannot be delegated to an AP.
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Correct Answer is D
Explanation
Rationale:
A. Blood for PaCO2 is a specialized specimen that requires venipuncture and specific handling to ensure accuracy, which should be performed by a licensed nurse or phlebotomist.
B. Random stool specimen collection is a routine task that can be delegated to the AP. It requires minimal specialized skill and is within the AP's scope of practice.
C. Wound drainage for culture requires sterile technique and proper handling to avoid contamination, which is beyond the AP's responsibilities.
D. Urine from an indwelling catheter requires specialized techniques and knowledge to ensure proper collection, and should be performed by a nurse.
Correct Answer is A
Explanation
Rationale:
A. Ask the AP about her concerns with the assignment is appropriate as it allows the nurse to understand and address any potential issues or reasons for refusal.
B. Report the AP to the charge nurse should only be done if the refusal cannot be resolved through discussion.
C. Take the specimen to the laboratory should be done if needed, but it is important to first understand why the AP refused.
D. Complete an incident report might be premature without understanding the reason behind the refusal.