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?

Correct Answer: C

Rationale: Rationale: - The nurse should assess the client's sacrum for edema as it requires nursing assessment skills. - Administering an enema and assisting a client to cough and deep breathe are within the scope of the AP's duties. - Application of antiembolic stockings can also be delegated to the AP, as it is a task requiring basic nursing skills. - Therefore, the nurse should plan to perform the task of assessing a client's sacrum for edema.

Correct Answer: D

Rationale: The correct answer is D: Provide a clear description of the task to the AP. This is essential to ensure the task is understood and completed accurately. Assessing the AP's ability to follow a teaching plan (A) is not relevant to task delegation. Determining social skills (B) and evaluating ability to work with peers (C) are also not directly related to task delegation. Providing clear instructions (D) is crucial for effective delegation and ensuring the task is performed correctly.

Correct Answer: D

Rationale: The correct answer is D because according to HIPAA regulations, a client's medical records are confidential and can only be shared with the client's permission. The nurse should inform the family member that the client must provide permission to access the medical records. A: Asking the nursing supervisor to obtain the medical records is not appropriate as it bypasses the client's right to privacy. B: The health care provider cannot share the information without the client's consent. C: Involving the ethics committee is unnecessary and does not address the issue of the client's permission. In summary, choice D is correct as it upholds the client's right to privacy and follows legal and ethical guidelines. Choices A, B, and C are incorrect as they do not consider the client's autonomy and confidentiality.

Correct Answer: D

Rationale: Rationale for Correct Answer D: 1. Notify the nursing supervisor: This is the appropriate action to ensure patient safety and address the provider's behavior through the appropriate channels. 2. Counseling the provider (Option A) may not be effective as immediate action is needed. 3. Encouraging clients to change providers (Option B) does not address the underlying issue. 4. Informing the state medical board (Option C) could be premature without internal investigation.

Correct Answer: A

Rationale: The correct answer is A: Sensory perceptual alterations related to decreased vision. Elderly clients with decreased vision are at greater risk for falls due to impaired depth perception, reduced awareness of obstacles, and difficulty navigating their environment. This nursing diagnosis directly impacts the client's ability to detect potential fall hazards. Incorrect Choices: B: Alteration in mobility related to fatigue - Fatigue may contribute to falls but is not as directly related to fall risk as sensory perceptual alterations. C: Impaired gas exchange related to retained secretions - This nursing diagnosis is not directly associated with an increased risk of falls. D: Altered patterns of urinary elimination related to nocturia - Nocturia may impact mobility during nighttime bathroom trips but is not as critical in fall risk assessment compared to sensory perceptual alterations.