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. Insisting the client take medications does not respect the client’s autonomy and is not an advocacy action.
B. Informing the client that the medication is the same as taken at home does not necessarily address the client’s concerns or questions.
C. Telling the client that refusal is noncompliance does not support client autonomy and does not address their concerns.
D. Encouraging the client to verbalize questions supports their right to be informed and make decisions about their care, demonstrating advocacy.
Correct Answer is C
Explanation
Rationale:
A. "I had strep throat about one year ago" is not directly related to contraindications for glyburide.
B. "I got my flu shot at the pharmacy two weeks ago" does not affect the use of glyburide.
C. "I plan to continue nursing my baby until he is at least a year old" indicates a contraindication because glyburide is not recommended for use during breastfeeding due to potential effects on the infant.
D. "I am allergic to shellfish" is not relevant to the contraindications for glyburide.