An assistive personnel (AP) reports to the nurse that a client who is 3 days postoperative following an abdominal hysterectomy has a dressing that is saturated with blood. Which of the following tasks should the nurse delegate to the AP?
Palpate for possible bladder distention.
Observe the incision site.
Change the abdominal dressing.
Obtain vital signs.
The Correct Answer is D
Rationale:
A. Palpate for possible bladder distention is a task that requires nursing assessment skills and should be done by the nurse.
B. Observe the incision site is a nursing task that involves assessing for signs of complications.
C. Change the abdominal dressing requires sterile technique and should be done by a nurse to prevent infection and ensure proper care.
D. Obtain vital signs is within the AP’s scope of practice and is a task that can be delegated. It is important for monitoring the client’s status and identifying potential issues.
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Correct Answer is C
Explanation
Rationale:
A. Opening a sterile tray flap toward the body can be incorrect practice, but it is a minor procedural issue that does not necessarily pose an immediate risk.
B. Using clean gloves is appropriate for non-sterile tasks like discontinuing an IV infusion.
C. Using a telephone number as identification is not acceptable; proper identification should include at least two identifiers like name and date of birth.
D. Emptying a colostomy pouch when it is one-third full is appropriate practice to prevent overflow and maintain hygiene.
Correct Answer is B
Explanation
Rationale:
A. Right circumstances refers to the appropriate conditions and setting for delegation.
B. Right supervision involves monitoring and evaluating the performance of tasks delegated to ensure they are completed correctly.
C. Right communication involves clearly communicating the tasks to be completed.
D. Right person ensures the task is delegated to someone with the appropriate skills and qualifications.