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A nurse is planning client care for herself and an assistive personnel (AP) working with her. Which of the following tasks should the nurse plan to perform?
- A. Assisting a client to cough and deep breathe
- B. Application of antiembolic stockings
- C. Administration of an enema
- D. Assessing a client's sacrum for edema
Correct Answer: D
Rationale: The correct answer is D. The nurse should plan to perform the task of assessing a client's sacrum for edema. This task requires critical thinking and nursing judgment to assess for potential complications such as pressure ulcers. Nurses are trained to assess and identify abnormalities in a client's condition.
Choice A: Assisting a client to cough and deep breathe can be delegated to the AP as it is within their scope of practice.
Choice B: Application of antiembolic stockings is a task that can be safely delegated to the AP as it is a routine procedure that does not require nursing assessment.
Choice C: Administration of an enema is a task that can be delegated to the AP as it is a routine procedure that does not require nursing assessment.
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A nurse is planning to delegate tasks to a licensed practical nurse (LPN). Which of the following entities is important for the nurse to understand when delegating tasks to the LPN?
- A. The National Council of State Boards of Nursing Decision Tree
- B. The state Nurse Practice Act
- C. The Omnibus Budget Reconciliation Act of 1987
- D. The National Association for Practical Nurse Education and Services
Correct Answer: B
Rationale: The correct answer is B: The state Nurse Practice Act. The Nurse Practice Act outlines the scope of practice and legal responsibilities for nurses in each state. When delegating tasks to an LPN, the nurse must adhere to the regulations and guidelines set forth in the Nurse Practice Act to ensure safe and appropriate delegation. Understanding this act is crucial to prevent legal and ethical violations.
Incorrect Choices:
A: The National Council of State Boards of Nursing Decision Tree - While this resource provides guidance on delegation, the Nurse Practice Act holds legal authority.
C: The Omnibus Budget Reconciliation Act of 1987 - This act relates to healthcare financing and does not specifically address the delegation of tasks to LPNs.
D: The National Association for Practical Nurse Education and Services - This organization focuses on education and services for LPNs but does not dictate legal guidelines for delegation.
An assistive personnel (AP) comes to work with a new set of artificial nails. The nurse takes the AP to a private location to discuss the issue. Which of the following statements by the nurse is appropriate?
- A. I want you to review the facility's policy on personal attire before you begin the shift.
- B. There is a higher risk of infection for our clients associated with artificial nails.
- C. Why would you wear artificial nails to work when you know it's against the rules?
- D. You should know that artificial nails have a very unprofessional appearance.
Correct Answer: B
Rationale: The correct answer is B: There is a higher risk of infection for our clients associated with artificial nails. This statement is appropriate because it directly addresses the potential harm that the AP's artificial nails could pose to clients. Artificial nails can harbor bacteria and increase the risk of transmitting infections in a healthcare setting. It focuses on the importance of infection control and patient safety.
Other choices are incorrect:
A: While reviewing facility policy is important, it does not directly address the issue of infection risk.
C: This statement is accusatory and does not promote a constructive dialogue about infection control.
D: Commenting on appearance is not relevant to the infection risk associated with artificial nails.
A charge nurse is working with an assistive personnel (AP) who provides excellent care to clients and is an effective team member. Which of the following actions should the nurse take first to recognize the AP's contributions to client care?
- A. Tell other nurses what an effective team member the AP is.
- B. Detail the AP's contributions to the nurse manager.
- C. Nominate the AP for the Employee of the Month award.
- D. Give positive feedback directly to the AP.
Correct Answer: D
Rationale: The correct answer is D: Give positive feedback directly to the AP. This is the first action the nurse should take because it directly acknowledges and reinforces the AP's contributions. Providing feedback directly shows appreciation and motivates the AP to continue their excellent work. It helps build a positive relationship and boosts morale.
Choice A is less effective as it does not directly recognize the AP's efforts and may not reach the AP. Choice B involves an intermediary and may delay recognition. Choice C is a formal recognition and may not provide immediate feedback to the AP. Thus, giving direct positive feedback to the AP is the most immediate and impactful way to recognize their contributions.
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.
A nurse is teaching a class on torts. The nurse should include which of the following situations as an example of negligence?
- A. A client who is alert and oriented makes an informed decision to leave the hospital against medical advice. The nurse applies restraints to the client to prevent him from leaving.
- B. A nurse identifies the absence of peripheral pulsation in a casted extremity in the early morning and reports it to the provider in the early afternoon.
- C. A client who is competent refuses an antidepressant medication. The nurse dissolves the medication in food and administers it to her without her knowledge.
- D. A nurse finds a client who is on a low-sodium diet eating salted potato chips. The nurse tells the client that she will apply wrist restraints if he does not stop eating the potato chips.
Correct Answer: C
Rationale: The correct answer is C because administering medication without the client's knowledge and against their refusal constitutes a breach of the duty of care and violates the client's autonomy and right to make decisions about their own treatment. This is an example of negligence as it goes against the ethical principle of informed consent. Choices A, B, and D do not meet the criteria for negligence as they involve actions taken in the best interest of the client, such as preventing harm or reporting concerning findings to the provider. In choice A, the nurse is trying to prevent harm by applying restraints to a client who is making a potentially harmful decision. In choice B, the nurse is identifying and reporting a concerning clinical finding promptly. In choice D, the nurse is attempting to educate the client and prevent harm related to dietary restrictions.