A nurse in the medical-surgical unit is assigning client care to a nurse who is floating from the PACU. The nurse should recognize that the float nurse is most qualified to care for which of the following clients?
A client who is being discharged to a long-term care facility
A client who is postoperative following a lobectomy and has a chest tube
A client who needs teaching about insulin self-administration
A client who needs teaching prior to initiating cardiac rehabilitation activities
The Correct Answer is B
A. A client being discharged to a long-term care facility may need comprehensive discharge planning, which involves familiarity with long-term care requirements, but this is not typically within the primary expertise of a PACU nurse.
B. A client who is postoperative following a lobectomy and has a chest tube falls within the PACU nurse's area of expertise. PACU nurses are experienced in monitoring and managing postoperative clients, including those with chest tubes, as these clients require close monitoring for complications such as respiratory distress or chest tube malfunction.
C. Teaching about insulin self-administration is important, but this task is more suited to nurses experienced in chronic care management, such as those from medical-surgical or endocrinology units.
D. Teaching prior to initiating cardiac rehabilitation requires specialized knowledge in cardiac care, which may not be the primary focus of a PACU nurse's practice.
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Related Questions
Correct Answer is ["C","D"]
Explanation
A. While low back pain can be concerning, it's not an immediate priority compared to the vital sign changes. However, the nurse should document the pain and ask about its characteristics.
B. Brown-colored urine can sometimes indicate dehydration or certain medical conditions, requiring follow-up.
C. A significant drop in blood pressure (74/50 mmHg) indicates hypotension and requires immediate attention.
D. An increase in respiratory rate (28 breaths/min) suggests the client may be experiencing respiratory distress and needs evaluation.
E. The client’s oxygen saturation is 95% on room air which is normal.
Correct Answer is D
Explanation
A. Providing written materials with large print helps accommodate low literacy levels by enhancing readability and comprehension, but assessing the client’s ability to demonstrate the skill is more crucial to assess understanding.
B. Long teaching sessions can overwhelm clients with low literacy levels and may not improve understanding.
C. Using acronyms may confuse clients with low literacy levels if they are not familiar with medical abbreviations.
D. Asking the client to demonstrate the skill is important, since it allows the nurse to assess the client's comprehension and correct any mistakes during the learning process.
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