A nurse and an assistive personnel (AP) are caring for a client who requests a PRN pain medication. After the nurse administers the medication, which of the following tasks should the nurse assign to the AP?
Document the client's respiratory rate in 1 hr.
Monitor the client for an allergic reaction for 30 min.
Check the client's response to the medication in 1 hr.
Evaluate the client for therapeutic effects in 30 min.
The Correct Answer is A
A. Documenting the client's respiratory rate in 1 hour is within the scope of practice for an assistive personnel (AP) and does not require nursing judgment or assessment.
B. Monitoring the client for an allergic reaction for 30 minutes requires nursing judgment and assessment skills to recognize signs and symptoms of allergic reactions.
C. Checking the client's response to the medication in 1 hour requires nursing judgment and assessment skills to evaluate pain relief and any adverse effects.
D. Evaluating the client for therapeutic effects in 30 minutes requires nursing judgment and assessment skills to determine the effectiveness of the pain medication.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A client who has a head injury and whose pupils are fixed and dilated: This client likely has a severe head injury with signs of increased intracranial pressure, which requires urgent intervention. However, airway and breathing take precedence over neurological status in triage. B. A client who has a dislocated shoulder and reports a pain level of 8 on a scale from 0 to 10: While this client is in pain, dislocated shoulder is not immediately life-threatening in the context of a mass casualty situation.
C. A client who has a 20.3-cm (8-in) scalp laceration with intermittent bleeding: Although this client has a significant laceration, it is not immediately life-threatening compared to compromised breathing.
D. A client who has diminished breath sounds and paradoxical chest movement: This client is likely experiencing a tension pneumothorax, a life-threatening condition that requires immediate intervention to decompress the chest and restore normal breathing.
Correct Answer is A
Explanation
A. Providing a tour of the perioperative area prior to surgery helps familiarize the adolescent with the environment, reducing anxiety and promoting a sense of control over the situation.
B. Explaining that anesthesia is a special type of sleep is oversimplifying and may not provide the adolescent with a clear understanding of the procedure. It's important to provide accurate information at a developmentally appropriate level.
C. Waiting until after surgery to explain the importance of coughing and deep breathing misses an opportunity for preoperative education. Teaching about postoperative care beforehand allows the adolescent to understand and participate in their own recovery process.
D. Keeping medical equipment out of the client's sight may reduce anxiety, but it does not address the adolescent's need for preparation and education about the surgical experience.
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