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 A
Explanation
Rationale:
A. Assessment includes the current status and vital signs of the client, which are part of the information the nurse provides to assess the client’s condition.
B. Situation describes the problem or concern that prompted the communication, not detailed vital signs.
C. Background provides context or history relevant to the situation but does not include current vital signs.
D. Recommendation involves suggesting actions or solutions but does not include the current condition details.
Correct Answer is B
Explanation
Rationale:
A. A client who has Guillain-Barre syndrome requires close monitoring and specialized care due to progressive weakness and potential respiratory issues. This client's care may involve more complex needs that are beyond the AP's scope.
B. A client who has a lumbosacral spinal tumor is likely to have fewer immediate needs related to eating assistance, making this task appropriate to delegate to the AP. The client’s primary concern may be mobility or pain management, but meal assistance is a routine task.
C. A client who has systemic sclerosis may have issues with gastrointestinal motility and swallowing, requiring more careful feeding assistance and monitoring, which should be performed by the nurse.
D. A client who has amyotrophic lateral sclerosis (ALS) requires specialized care for swallowing difficulties and respiratory issues, making it inappropriate to delegate meal assistance to the AP.