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 A
Explanation
Rationale:
A. Nurses and emergency medical personnel are trained and designated as triage officers during a disaster, responsible for assessing and prioritizing patients.
B. Law enforcement officers are crucial for security and crowd control but not typically involved in triage.
C. FEMA members provide overall disaster management but are not specifically triage officers.
D. American Red Cross representatives assist with disaster relief but do not handle triage responsibilities directly.
Correct Answer is A
Explanation
Rationale:
A. Assessment includes the current status and vital signs of the client, which are part of the information the nurse provides to assess the client’s condition.
B. Situation describes the problem or concern that prompted the communication, not detailed vital signs.
C. Background provides context or history relevant to the situation but does not include current vital signs.
D. Recommendation involves suggesting actions or solutions but does not include the current condition details.