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. Providing a back rub can be done by an AP, as it does not require specialized nursing skills.
B. Transporting a client is an appropriate task for an AP if the client is stable.
C. Performing oral hygiene for a postoperative client can be managed by an AP with supervision.
D. Removing and cleaning the cannula of a new tracheostomy requires specific skills and knowledge that only a licensed nurse should perform to avoid complications.
Correct Answer is D
Explanation
Rationale:
A. The nurse coats the indwelling urinary catheter with lubricant is correct and necessary for the procedure to reduce discomfort and facilitate insertion.
B. The nurse applies the sterile drape prior to inserting the urinary catheter is a proper step to maintain a sterile field during the procedure.
C. The nurse provides perineal care prior to inserting the urinary catheter is appropriate as it ensures cleanliness before catheter insertion.
D. The nurse separates the client's labia with her dominant hand should not be done; the non-dominant hand should be used to hold the labia apart to maintain sterility.