A nursing assistant may be responsible for determining:
A. Vital signs
B. Cranial nerve function
C. Neck vein distention
D. Auscultation of bowel sounds
A
A. Assistive personnel can be trained to count apical pulse and peripheral pulses after the nurse's initial assessment. Assistive personnel need to be instructed to recognize temperature and color changes along with changes in peripheral pulses.
B and C. Comprehensive heart and neck vessel assessment should not be delegated to assistive personnel.
D. The order of an abdominal assessment differs from that of other assessments. The nurse begins with inspection and follows with auscultation. It is important to auscultate before palpation and percussion because these maneuvers may alter the frequency and character of bowel sounds. This skill should not be delegated to assistive personnel. However, assistive personnel should know to report the development of abdominal pain or changes in the client's bowel habits or dietary intake.
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