A nurse is assisting with the care of a client who is experiencing a cardiac arrest. Which of the following tasks should the nurse assign to an assistive personnel?

Perform CPR on the client.

Assist with airway intubation.

Place defibrillator pads on the client.

Maintain IV access.

Answer and Explanation

The Correct Answer is A

A) Perform CPR on the client:

Performing CPR is a critical intervention during cardiac arrest to maintain circulation and oxygenation. Assistive personnel are trained in basic CPR techniques and can effectively administer chest compressions according to established protocols. Assigning this task to assistive personnel allows the nurse to focus on other aspects of resuscitation and coordination of care.

B) Assist with airway intubation:

Airway intubation requires specialized training and skills, typically performed by licensed healthcare providers such as nurses or physicians. While assistive personnel may assist with preparing equipment or positioning the client, they are not trained to perform airway intubation procedures.

C) Place defibrillator pads on the client:

Placing defibrillator pads requires knowledge of proper positioning and electrode placement to deliver effective defibrillation shocks. This task is typically performed by healthcare providers with training in advanced cardiac life support (ACLS). Assistive personnel may assist with tasks such as preparing the client's chest and clearing the area for defibrillation, but they do not typically apply the pads themselves.

D) Maintain IV access:

Maintaining IV access involves monitoring the IV site, adjusting flow rates, and administering medications or fluids as ordered. While assistive personnel may assist with tasks related to IV access, such as holding the IV bag or adjusting tubing, they are not typically responsible for the overall management and maintenance of IV access during a cardiac arrest situation.

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Correct Answer is B

Explanation

A) Administer PRN haloperidol IM to the client:

Administering haloperidol is not the first-line intervention for managing behavioral disturbances in clients with dementia, especially in response to acute agitation. While antipsychotic medications like haloperidol may be prescribed in some cases, they should be used judiciously due to the risk of adverse effects, particularly in elderly clients. Additionally, administering medication should not be the first action taken without attempting non-pharmacological interventions.

B) Engage the client in a repetitive activity as a distraction:

This is the most appropriate initial intervention when dealing with an agitated client with dementia. Engaging the client in a repetitive, calming activity can help redirect their focus and reduce agitation. Simple, familiar tasks or activities tailored to the client's preferences can be effective in providing comfort and reducing distress.

C) Apply wrist restraints to the client:

Using physical restraints should be avoided unless absolutely necessary for the safety of the client or others. Restraints can cause physical and psychological harm, increase agitation, and compromise the client's dignity and autonomy. Therefore, restraint use should be a last resort and implemented only after other interventions have been attempted and deemed ineffective or when there is an imminent risk of harm.

D) Place the client in a seclusion room:

Seclusion should not be used as an initial intervention for managing agitation in clients with dementia. Seclusion can exacerbate distress and increase feelings of isolation and fear, which may escalate agitation further. It should only be considered as a last resort for managing severe agitation or aggression when all other interventions have failed and there is a risk of harm to the client or others.

A. The client rates her pain at a 3 on a 0 to 10 pain rating scale B. The client has type 2 diabetes mellitus." C. The client is 2 hours postoperative following a cholecystectomy. D. The client should wear compression stockings."

Correct Answer is A

Explanation

A) The client rates her pain at a 3 on a 0 to 10 pain rating scale:

In the SBAR communication technique, "A" stands for "Assessment." This portion of the report should include concise and pertinent information about the client's current condition or status. The client's pain level, rated on a standardized pain scale, is a crucial assessment parameter that provides immediate insight into the client's comfort and potential need for intervention or further assessment.

B) The client has type 2 diabetes mellitus:

While the client's medical history of type 2 diabetes mellitus is important information, it is more relevant to the client's overall health status and background. In the SBAR framework, this information would typically be included in the "B" (Background) portion of the report, which focuses on contextual information such as medical history, current diagnoses, and relevant background information about the client.

C) The client is 2 hours postoperative following a cholecystectomy:

The fact that the client is 2 hours postoperative following a cholecystectomy is significant information regarding the client's recent surgical procedure and immediate postoperative status. However, this information falls under the "B" (Background) portion of the SBAR report, which includes details about the client's recent events, procedures, or treatments.

D) The client should wear compression stockings:

Information about the client's prescribed interventions or treatments, such as wearing compression stockings, is essential for continuity of care and ensuring that appropriate interventions are continued. However, this information is typically included in the "R" (Recommendation) portion of the SBAR report, where the nurse may provide recommendations for ongoing care or interventions based on the client's current condition and needs.

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A nurse is assisting with the care of a client who is experiencing a cardiac arrest. Which of the following tasks should the nurse assign to an assistive personnel?

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