Examkin

Soru

Zorluk: ZorAssignment, Delegation and Supervision

A client is receiving a continuous intravenous heparin infusion for an acute deep vein thrombosis (DVT) in the left lower extremity. When organizing the daily care plan, which instruction from the registered nurse (RN) to the unlicensed assistive personnel (UAP) represents appropriate delegation?

  1. A
    Engage the knee-gatch mechanism on the bed to slightly bend the client's knees and promote comfort.
  2. B
    Evaluate the client's level of understanding regarding the purpose of the continuous intravenous anticoagulant.
  3. Assist the client with morning hygiene while ensuring the use of a soft-bristled toothbrush and an electric razor.Cevap
  4. D
    Monitor the client's gums, urine, and stool for any signs of spontaneous bleeding throughout the shift.

Cevap

The correct instruction is to assist the client with morning hygiene while ensuring the use of a soft-bristled toothbrush and an electric razor.
Assisting a client with activities of daily living (ADLs), such as personal hygiene, is entirely within the UAP's scope of practice. By specifically directing the UAP to use a soft-bristled toothbrush and an electric razor, the RN is correctly applying the 'Right Direction/Communication'. The RN has adapted a routine, delegable task to safely accommodate the client's high risk for bleeding due to the continuous heparin infusion.

Adım Adım Çözüm

1
Analyze the client's clinical status and associated risks.
The client has a DVT and is on a continuous heparin infusion, establishing a high risk for spontaneous bleeding and a risk for pulmonary embolism if the thrombus is dislodged.
Understanding the client's physiological vulnerabilities is required to determine the 'Right Circumstance' for delegation.
2
Evaluate the scope of practice for the Unlicensed Assistive Personnel (UAP).
UAPs can perform routine, standard procedures (like ADLs and hygiene) on stable clients but cannot perform assessments, teaching, or evaluation (EAT), nor can they perform tasks requiring clinical nursing judgment.
Delegation must strictly align with the established NCSBN boundaries for assistive personnel.
3
Critique each instruction against the five rights of delegation and DVT safety protocols.
Monitoring and evaluating are RN-only functions. Using the knee-gatch is physically dangerous for a DVT. Assisting with hygiene using specific bleeding precautions is safe and delegable.
Eliminating inappropriate or dangerous tasks isolates the single safe delegation choice.

Anahtar Kavram

Delegation of tasks to UAP considering clinical contraindications and bleeding precautions
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Konular

Assignment, Delegation and Supervision

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