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A charge nurse is reviewing the list of tasks that have been delegated to the assistive personnel (AP) by the staff nurse. Which of the following tasks should the charge nurse reassign to a licensed nurse?
- A. Providing a back rub to a client who has right-sided paralysis
- B. Transporting a client who experienced a stroke 72 hr ago to the radiology department
- C. Performing oral hygiene for a client who is 1 day postoperative following an amputation of the right arm
- D. Removing and cleaning the cannula of a client who has a new tracheostomy
Correct Answer: D
Rationale: The correct answer is D because removing and cleaning the cannula of a client with a new tracheostomy requires specialized skills and knowledge that only a licensed nurse possesses to prevent complications and ensure safety. Providing a back rub (A) can be delegated to an AP as it is within their scope of practice. Transporting a stroke client (B) and performing oral hygiene post-amputation (C) can also be delegated as they do not involve complex nursing assessments or interventions. It is crucial to reassign the tracheostomy care task to a licensed nurse to maintain the client's airway safely.
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A nurse manager along with members of the nurse practice committee are conducting a skills day for assistive personnel in the medical surgical unit to validate competency. Which skills demonstrated by assistive personnel require immediate follow-up. Select the '3' findings that require immediate follow-up.
- A. AP 1-Quickly pulls fire alarm, then proceeds to remove the client from room. AP 3-Raised bedrails of the bed for client who was reported not alert or oriented, and was sleeping.
- B. AP 2-Verifies with nurse the order in which protective equipment should be removed.
- C. AP 7- While disinfecting portable vital sign monitor wore gloves and washed hand prior to leaving room.
- D. AP 6 - During simulation, which included assisting client into bed, there was no observed handwashing.
- E. AP 5-Following simulation, was unable to identify the locations of alarms on medical surgical unit.
- F. AP 4-Successfully completed skills of simulation including emptying the client's trash can
Correct Answer: A,D,E
Rationale: The correct answer is A, D, and E. Option A requires follow-up because pulling the fire alarm before removing the client may result in leaving the client in a dangerous situation. Option D needs follow-up because not washing hands after assisting a client into bed can lead to the spread of infection. Option E warrants follow-up as not knowing the alarm locations could delay response to emergencies. Options B, C, and F are not immediate concerns as they demonstrate proper procedures or successful completion of tasks.
A nurse on a medical-surgical unit is providing care for a group of clients. The nurse should delegate collection of which of the following specimens to the assistive personnel (AP)?
- A. Blood for PaCO2
- B. Random stool specimen
- C. Wound drainage for culture
- D. Urine from an indwelling catheter
Correct Answer: B
Rationale: The correct answer is B: Random stool specimen. The rationale is that collecting a random stool specimen does not require specialized training or skills, making it appropriate for assistive personnel (AP) to perform. Collecting blood for PaCO2 (A) requires specific training and knowledge of arterial blood gas sampling. Wound drainage for culture (C) involves sterile technique and knowledge of wound care. Urine from an indwelling catheter (D) requires knowledge of catheter care and sterile technique. Therefore, delegating the collection of a random stool specimen to AP is the most appropriate choice.
A nurse manager is reviewing the admission history of four adults who were admitted to the medical-surgical unit during the shift. Which of the following situations is the nurse required to disclose information to an outside agency about the client or the client's circumstances?
- A. A young adult client admitted for acute glomerulonephritis following a viral infection
- B. A dependent adult admitted for the treatment of a spiral fracture
- C. A young adult client admitted for asthma and has track marks that may indicate IV drug abuse
- D. An emancipated minor who has acute appendicitis and wants to leave the facility without treatment
Correct Answer: B
Rationale: The correct answer is B because a dependent adult admitted for the treatment of a spiral fracture falls under mandatory reporting requirements for suspected abuse or neglect. The nurse is obligated to disclose information to an outside agency to ensure the safety and well-being of the patient. In cases of suspected abuse or neglect, it is crucial to involve external agencies to investigate and protect the vulnerable adult.
Choices A, C, and D do not necessarily involve mandatory reporting to an outside agency. A young adult with glomerulonephritis or asthma with possible IV drug abuse may not require immediate disclosure unless there is a clear indication of harm or risk to the patient. An emancipated minor with acute appendicitis wanting to leave without treatment raises ethical concerns but may not involve mandatory reporting unless there are specific legal requirements in place.
At the beginning of the shift, an RN is preparing assignments for a licensed practical nurse (LPN) and an assistive personnel (AP). Which of the following tasks should the nurse assign to the LPN?
- A. Measuring a client's 1&O
- B. Obtaining a client's weight
- C. Providing postmortem care for a client
- D. Inserting a nasogastric tube for a client
Correct Answer: D
Rationale: Correct Answer: D - Inserting a nasogastric tube for a client
Rationale: LPNs are trained to perform more complex nursing tasks than APs. Inserting a nasogastric tube requires specialized skills and knowledge that LPNs are educated and licensed to carry out safely. LPNs have the training to assess, insert, and manage nasogastric tubes under the supervision of an RN, making this task appropriate for delegation to an LPN.
Incorrect Choices:
A: Measuring a client's 1&O - This task can be safely performed by an AP as it does not require the clinical judgment and skills of an LPN.
B: Obtaining a client's weight - This is within the scope of practice for an AP and does not require the nursing expertise of an LPN.
C: Providing postmortem care for a client - This task involves specialized knowledge and emotional support, typically handled by RNs, not LPNs.
A nurse in a provider's office is reviewing the laboratory findings for a client who is scheduled for surgery. Which of the following findings requires follow up by the nurse?
- A. WBC 6,000/mm3
- B. BUN 15 mg/dL
- C. Hemoglobin 14 g/dL
- D. Platelet count 60,000/mm3
Correct Answer: D
Rationale: The correct answer is D: Platelet count 60,000/mm3. A low platelet count (thrombocytopenia) can increase the risk of bleeding during surgery. Normal platelet count is around 150,000-450,000/mm3. The other options are within normal ranges: A) WBC 6,000/mm3 is normal, B) BUN 15 mg/dL is normal, and C) Hemoglobin 14 g/dL is normal. Therefore, the nurse should follow up on the platelet count to ensure the client's safety during surgery.