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A nurse is caring for a client who is experiencing alcohol withdrawal. Which of the following tasks should the nurse delegate to an assistive personnel (AP)?
- A. Monitor the client's vital signs every 4 hours.
- B. Administer a prescribed benzodiazepine.
- C. Assess the client for tremors or agitation.
- D. Provide the client with a quiet environment.
Correct Answer: D
Rationale: The correct answer is D: Provide the client with a quiet environment. This task can be delegated to an assistive personnel (AP) because it involves creating a suitable environment for the client, which does not require specialized nursing skills. Assisting the client in a quiet environment can help minimize triggers and promote calmness during alcohol withdrawal.
A: Monitoring vital signs every 4 hours requires nursing judgment to interpret the results and decide on appropriate interventions.
B: Administering a benzodiazepine is a medication administration task that should be done by a nurse who can assess the client's condition and response to the medication.
C: Assessing the client for tremors or agitation involves clinical judgment and requires a nurse's expertise to determine the appropriate interventions.
In summary, providing a quiet environment is a task that can be safely delegated to an assistive personnel, while the other options involve assessments, medication administration, and clinical judgment that are within the scope of nursing practice.
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A charge nurse is reviewing the documentation of a newly licensed nurse. Which of the following entries requires follow-up?
- A. Client received 2 mg morphine IV at 0900 for pain rated 6/10.
- B. Client's blood pressure is normal after medication administration.
- C. Client refused morning medications; provider notified.
- D. Client's wound dressing changed at 1100 per protocol.
Correct Answer: B
Rationale: Describing blood pressure as 'normal' is vague and lacks specific data, requiring follow-up to ensure accurate and complete documentation.
A nurse is caring for a client who is postoperative. Which of the following should the nurse request as a recommendation in an SBAR report to the provider? Select All That Apply
- A. Medication for elevated temperature
- B. Insertion of NG tube for decompression
- C. Oxygen 2 to 4 L/min via nasal cannula
- D. Insertion of urinary catheter
- E. Evaluation of surgical wound drain
Correct Answer: A,E
Rationale: The correct choices are A and E. Requesting medication for an elevated temperature (choice A) is important as it indicates a potential sign of infection postoperatively. Evaluation of the surgical wound drain (choice E) is crucial to monitor for any signs of infection or complications. Choices B, C, and D are not appropriate for an SBAR report as they do not directly address postoperative care needs. NG tube insertion (choice B) and urinary catheter insertion (choice D) are invasive procedures that should not be requested without a specific indication. Oxygen therapy (choice C) may be necessary but is not the priority in this case.
A nurse is delegating client care assignments for the shift. Which of the following tasks should the nurse delegate to an assistive personnel (AP)?
- A. Teach a client about low-sodium foods.
- B. Measure and record intake and output for a client.
- C. Perform wound irrigation for a client.
- D. Evaluate pain relief for a client following the administration of a pain medication.
Correct Answer: B
Rationale: The correct answer is B: Measure and record intake and output for a client. This task can be safely delegated to an assistive personnel (AP) as it is a non-invasive and routine task that does not involve critical thinking or interpretation. APs are trained to perform basic tasks like measuring and recording intake and output accurately under the supervision of a nurse. Other choices are incorrect because: A involves providing client education which requires critical thinking and assessment skills, C involves a procedure that requires specific training and skill, and D involves evaluating the effectiveness of pain relief which requires nursing judgment and assessment skills.
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?
- A. Palpate for possible bladder distention.
- B. Observe the incision site.
- C. Change the abdominal dressing.
- D. Obtain vital signs.
Correct Answer: D
Rationale: The correct answer is D: Obtain vital signs. Vital signs are essential to assess the client's overall condition and determine the urgency of the situation. The AP can measure and report the vital signs to the nurse promptly. Palpating for bladder distention (choice A) requires a higher level of assessment and may indicate a complication postoperatively. Observing the incision site (choice B) involves assessing for signs of infection or other complications, which should be done by a nurse. Changing the abdominal dressing (choice C) requires sterile technique and assessment skills beyond the AP's scope. Therefore, delegating these tasks to the AP could delay necessary interventions.
A nurse is triaging clients in an urgent care clinic. Which of the following clients should the nurse have the provider care for immediately?
- A. A middle adult male who is diaphoretic and reports epigastric pain
- B. A toddler who has a laceration on his forehead and is screaming
- C. An adolescent female client who is belligerent and has slurred speech
- D. A young adult with a painful sunburn of his face and arms
Correct Answer: A
Rationale: The correct answer is A. The nurse should have the provider care for the middle adult male who is diaphoretic and reports epigastric pain immediately. Diaphoresis and epigastric pain can be signs of a heart attack or other serious cardiac issue, requiring urgent medical attention to prevent complications. The other choices do not present an immediate life-threatening situation. The toddler with a laceration can be addressed after stabilizing the critical client. The belligerent adolescent may need behavioral intervention but does not require immediate medical attention. The young adult with sunburn, while painful, is not a life-threatening condition that requires immediate provider care.