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. Inform the state medical board for an immediate investigation is not the initial step; concerns should first be reported to appropriate facility personnel.
B. Counsel the provider to determine the cause of the substance abuse is not the nurse’s role; this is a serious issue that requires reporting rather than counseling.
C. Notify the nursing supervisor of the concerns is the appropriate initial step to address the issue according to facility protocol.
D. Encourage clients to change to a different provider is not within the nurse’s scope of practice for handling the provider's behavior and does not address the root issue.
Correct Answer is D
Explanation
Rationale:
A. Blood for PaCO2 is a specialized specimen that requires venipuncture and specific handling to ensure accuracy, which should be performed by a licensed nurse or phlebotomist.
B. Random stool specimen collection is a routine task that can be delegated to the AP. It requires minimal specialized skill and is within the AP's scope of practice.
C. Wound drainage for culture requires sterile technique and proper handling to avoid contamination, which is beyond the AP's responsibilities.
D. Urine from an indwelling catheter requires specialized techniques and knowledge to ensure proper collection, and should be performed by a nurse.