Emergency Nursing & Triage Q 30 - Gyan Darpan : Learning Portal
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Wednesday, 23 March 2022

Emergency Nursing & Triage Q 30

The physician has ordered cooling measures for a child with a fever who is likely to be discharged when the temperature comes down. Which task would be appropriate to delegate to a nursing assistant?
    A. Prepare and administer a tepid sponge bath
    B. Explain the need for giving cool fluids
    C. Assist the child in removing outer clothing
    D. Advise the parent to use acetaminophen (Tylenol) instead of aspirin

Correct Answer: C. Assist the child in removing outer clothing.

The nursing assistant can help with the removal of outer clothing, which allows the heat to dissipate from the child’s skin. The client is the center of care. The needs of the client must be competently met with the knowledge, skills and abilities of the staff to meet these needs. In other words, the nurse who delegates aspects of care to other members of the nursing team must balance the needs of the client with the abilities of those to which the nurse is delegating tasks and aspects of care, among other things such as the scopes of practice and the policies and procedures within the particular healthcare facility.

Option A: Tepid baths are not usually given because of the possibility of shivering and rebound. Registered nurses who assign, delegate, and/or provide nursing care to clients and groups of clients must report all significant changes that occur in terms of the client and their condition. For example, a significant change in a client’s laboratory values requires that the registered nurse report this to the nurse’s supervisor and doctor.
Option B: Explaining is a teaching function only appropriate for a registered nurse. The staff members’ levels of education, knowledge, past experiences, skills, abilities, and competencies are also evaluated and matched with the needs of all of the patients in the group of patients that will be cared for.
Option D: Advising is a teaching function that is the responsibility of the registered nurse. Delegation should be done according to the differentiated practice for each of the staff members. A patient care technician, a certified nursing assistant, a licensed practical nurse, an associate degree registered nurse, and a bachelor’s degree registered nurse should not be delegated to the same aspects of nursing care.

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