A nurse manager is providing an inservice program about delegation to assistive personnel (AP) with staff nurses on the unit. Which of the following statements by a staff nurse indicates an understanding of the teaching?
"The nurse relinquishes accountability for client outcomes when care is delegated to an AP."
"The nurse should consider the AP's level of experience when making delegation decisions."
"The AP can provide client education about how to perform basic self-care to the client."
"The AP can re-delegate a task to another AP who has similar work experience."
The Correct Answer is B
Rationale:
A. The nurse does not relinquish accountability when delegating tasks to an AP; the nurse remains responsible for the overall care and outcomes.
B. Considering the AP's level of experience is crucial for effective delegation to ensure that tasks are matched to the AP's skills and knowledge.
C. Providing client education is generally beyond the scope of AP duties and should be performed by a licensed nurse.
D. Re-delegating tasks is not allowed; the original delegator remains responsible for ensuring the task is completed properly and should delegate directly to the appropriate individual.
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Correct Answer is ["A","C","E"]
Explanation
Rationale:
A. Applying an ambulation alarm can help alert staff if the client tries to move independently, thus reducing the risk of falls.
B. Restraints should only be used as a last resort and require a physician’s order. They should not be used routinely for fall prevention.
C. Instructing the client in the use of the call light empowers them to request assistance, which can help prevent falls.
D. Raising all side rails can be considered a restraint and may increase the risk of falls or injury. It is not a recommended practice for fall prevention.
E. Checking on the client hourly ensures ongoing monitoring and timely intervention if needed, which is effective in preventing falls.
Correct Answer is B
Explanation
Rationale:
A. A client who is 3 days postoperative following a craniotomy requires careful monitoring due to potential complications from brain surgery, so vital signs should be taken by a nurse.
B. A client who is 3 days postoperative following gastric bypass surgery is stable enough for an AP to obtain vital signs, as the risk of immediate postoperative complications is lower compared to more recent surgeries.
C. A client who is 2 hr postoperative following an abdominal hysterectomy requires close monitoring due to the recent surgery, so vital signs should be obtained by a nurse.
D. A client who is 1 hr postoperative following a thyroidectomy requires vigilant monitoring for potential complications from recent surgery, which should be done by a nurse.