A long-term-care client with chronic lymphocytic leukemia has a nursing diagnosis of Activity Intolerance related to weakness and anemia. Which of these nursing activities is most appropriate for you, as the charge nurse, to delegate to a nursing assistant?

Correct Answer: B

Rationale: In the context of a long-term-care client with chronic lymphocytic leukemia experiencing activity intolerance due to weakness and anemia, delegating the task of checking the client's blood pressure and pulse rate after ambulation to a nursing assistant is the most appropriate choice. This task is within the scope of practice for a nursing assistant and directly relates to monitoring the client's physiological response to activity, which is crucial in assessing their tolerance levels and adjusting care plans accordingly. Option A, evaluating the client's response to normal activities of daily living, requires a higher level of clinical judgment and interpretation of findings, making it more suitable for a licensed nurse. Option C, determining self-care activities the client can do independently, involves assessing the client's functional abilities and should be done by a healthcare provider with a comprehensive understanding of the client's condition and limitations. Option D, assisting the client in choosing a diet to improve strength, involves nutritional assessment and individualized planning, which falls under the scope of a registered dietitian or a nurse with specific training in nutrition. Educationally, understanding the principles of delegation based on scope of practice and client needs is essential for effective healthcare team collaboration. By correctly delegating tasks, nurses can optimize efficiency, promote patient safety, and ensure quality care delivery tailored to each client's unique requirements. Nurses must possess a solid grasp of delegation principles to allocate responsibilities appropriately and maximize the effectiveness of the healthcare team.

Correct Answer: B

Rationale: In this scenario, the most immediate concern for the nurse is option B) The client has an oral temperature of 99.7°F. Explanation: 1. Correct Answer: A post-splenectomy patient is at risk for infection due to the spleen's role in filtering bacteria from the blood. A temperature of 99.7°F could indicate the presence of an infection, which is a serious concern considering the client's recent splenectomy. 2. Incorrect Options: A) Engaging in unprotected sex may raise concerns about sexually transmitted infections, but in this context, infection risk post-splenectomy is more critical. C) Abdominal pain with light palpation could be due to various reasons, but infection needs immediate attention. D) Occasional marijuana use, while important for overall health, is not the most immediate concern in this case. Educational Context: Understanding the increased risk of infection post-splenectomy is crucial for nurses in hematology/oncology. Assessing vital signs and promptly identifying signs of infection are essential to prevent serious complications in these patients. This question highlights the importance of prioritizing assessment findings based on the patient's unique health status.

Correct Answer: C

Rationale: In this scenario, assigning the LPN with 2 years of experience on the oncology unit to care for the client with a low ANC is the most appropriate choice. The LPN's familiarity with oncology unit protocols, procedures, and patient population makes them well-suited for this assignment. Their experience indicates they have likely received specific training in managing oncology patients, including those in protective isolation. Option A, the LPN from the same-day-surgery unit, lacks the specialized experience required for oncology care. Option B, the RN from the float pool with a background in surgical care, may not have the expertise needed for oncology patients. Option D, the RN from the ED, may also lack the specialized knowledge and skills necessary for caring for oncology patients in protective isolation. In an educational context, this question highlights the importance of matching staff expertise with the specific needs of patients in different care settings. It underscores the significance of experience and training in specialized areas like oncology, where patients often require complex care and interventions. By understanding the rationale behind staffing assignments, healthcare professionals can ensure the best possible outcomes for their patients.

Correct Answer: A

Rationale: In the context of a client with acute myelogenous leukemia undergoing induction chemotherapy, the most concerning assessment information is a serum potassium level of 7.8 mEq/L (Option A). Chemotherapy, especially in the induction phase, can lead to tumor lysis syndrome, causing a rapid release of intracellular contents into the bloodstream, including potassium. Hyperkalemia can lead to serious cardiac arrhythmias and must be addressed promptly. Option B, urine output less than intake by 400 mL, may indicate renal dysfunction, but hyperkalemia poses a more immediate threat to the client's life. Option C, inflammation and redness of oral mucosa, and Option D, ecchymoses present on the anterior trunk, are common manifestations of leukemia and its treatment but do not pose immediate life-threatening risks compared to severe hyperkalemia. Educationally, this question highlights the importance of prioritizing assessments in clients undergoing chemotherapy, specifically focusing on identifying potentially life-threatening complications. Understanding the significance of laboratory values and their implications for client care is crucial in providing safe and effective nursing interventions in oncology settings.

Correct Answer: A

Rationale: In this scenario, the correct answer is option A) Check the skin for signs of redness or peeling. Delegating this task to a nursing assistant is appropriate because it involves a basic observation skill that a nursing assistant can perform under supervision. Monitoring the skin for signs of redness or peeling is crucial in identifying early manifestations of radiation-induced skin reactions, which is a common side effect in clients receiving radiation therapy for Hodgkin's lymphoma in the groin area. Option B) Applying alcohol-free lotion after cleaning involves a level of judgment and understanding of the specific requirements for radiation-induced skin care, making it more suitable for a licensed nurse to perform. Option C) Explaining good skin care to the client and family requires a higher level of education and communication skills that are typically within the scope of a registered nurse or advanced practice nurse. Option D) Cleaning the skin over the area daily with a mild soap may seem like a simple task, but it is important to note that cleaning the skin of a client undergoing radiation therapy requires specific protocols and considerations to prevent further damage, making it more appropriate for a licensed nurse to carry out. Educationally, understanding the rationale behind delegating tasks based on the complexity and required skill level is crucial for effective and safe patient care delegation in healthcare settings. It ensures that tasks are assigned to the appropriate personnel based on their scope of practice, competency, and the specific needs of the patient.