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. Verify the AP's educational preparation prior to delegating the task is unnecessary if the AP has been trained and is competent in the task.
B. Observe the AP as she obtains the vital signs of each client is not required for routine tasks unless there is a concern about performance.
C. Determine the time frame the AP should report the results is crucial for ensuring timely and accurate reporting, which is necessary for effective patient care.
D. Ask the AP to take the vital signs of the client returning from surgery first might not be appropriate without considering the urgency of all clients’ conditions.
Correct Answer is C
Explanation
Rationale:
A. A child who is experiencing sickle cell crisis may require isolation to prevent infection and avoid complications related to sickle cell disease.
B. A child who has a head injury may require specific monitoring and precautions that are not suitable for a postoperative appendectomy patient.
C. A child who has a new diagnosis of type 1 diabetes mellitus generally has a stable condition that can be managed with routine care and would be an appropriate roommate for a postoperative appendectomy patient.
D. A child who has streptococcal pharyngitis could pose an infection risk to the postoperative appendectomy patient and is better kept separate to prevent the spread of infection.