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. Transporting a school-age client who is in traction involves handling a medical condition that may require specialized knowledge and skills beyond the volunteer’s capabilities.
B. Reading a book to a client who has AIDS is a supportive activity and does not pose significant risks.
C. Rocking an infant with croup is generally safe and provides comfort to the child.
D. Playing a computer video game with an adolescent is a non-medical activity that is appropriate for a volunteer.
Correct Answer is B
Explanation
Rationale:
A. Requesting a referral is important but not immediately critical compared to other needs.
B. Asking about a PCA pump with morphine indicates a potential issue with pain management or medication delivery that needs immediate attention.
C. Assisting with a bath is important for comfort and hygiene but is less urgent compared to immediate pain management.
D. Questions about a new prescription should be addressed but are generally less urgent than issues related to pain management.