A nurse is preparing to administer a soap suds enema to a client who has constipation. As the nurse explains the procedure, the client states, "The doctor didn't tell me I was supposed to receive an enema." Which of the following nursing actions is appropriate at this time?
Check the client's medical record for the provider's prescription.
Inform the charge nurse that the client refused the enema.
Explain to the client that the provider prescribed the procedure.
Assure the client that enemas are commonly prescribed for constipation.
The Correct Answer is A
Rationale:
A. Check the client's medical record for the provider's prescription is the appropriate action to confirm whether the enema was indeed ordered and to ensure that the client’s concerns are addressed.
B. Inform the charge nurse that the client refused the enema might be premature without first verifying the order and addressing the client's concerns.
C. Explain to the client that the provider prescribed the procedure is not appropriate if you have not confirmed the order. It may be premature if the order is not documented.
D. Assure the client that enemas are commonly prescribed for constipation does not address the client’s specific concern about whether the enema was actually ordered.
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Correct Answer is B
Explanation
Rationale:
A. The National Council of State Boards of Nursing Decision Tree provides guidance for decision-making but does not specifically address delegation.
B. The state Nurse Practice Act defines the scope of practice for RNs and LPNs and is essential for understanding what tasks can be delegated.
C. The Omnibus Budget Reconciliation Act of 1987 primarily pertains to nursing home regulations and does not directly address task delegation.
D. The National Association for Practical Nurse Education and Services focuses on LPN education and standards, but the state Nurse Practice Act is more directly relevant to delegation.
Correct Answer is C
Explanation
Rationale:
A. Determining social skills is not directly related to task delegation.
B. Assessing ability to follow the client's teaching plan is beyond the scope of AP duties.
C. Providing a clear description of the task ensures that the AP understands what is expected, which is essential for effective delegation.
D. Evaluating ability to work with peers is important but not the primary focus for task delegation.