A nurse is assisting with the care of a group of pediatric clients. Which of the following actions should the nurse take first?
Deliver a breakfast tray to a child who has been administered regular insulin.
Complete pin site care for a child who is in skeletal traction.
Provide clear liquids to a child who is 4 hr postoperative following a laparoscopic appendectomy.
Administer acetaminophen to a child who has a temperature of 101.2°F (38.4°C).
The Correct Answer is A
If a nurse is assisting with the care of a group of pediatric clients, the first action the nurse should take is to deliver a breakfast tray to a child who has been administered regular insulin. This is because regular insulin is a fast-acting insulin that begins to lower blood sugar levels within 15 minutes of administration. It is important for the child to eat shortly after receiving regular insulin to prevent hypoglycemia.
Option B is incorrect because completing pin site care for a child who is in skeletal traction is not as time-sensitive as delivering a breakfast tray to a child who has been administered regular insulin.
Option C is incorrect because providing clear liquids to a child who is 4 hr postoperative following a laparoscopic appendectomy is not as time-sensitive as delivering a breakfast tray to a child who has been administered regular insulin.
Option D is incorrect because administering acetaminophen to a child who has a temperature of 101.2°F (38.4°C) is not as time-sensitive as delivering a breakfast tray to a child who has been administered regular insulin.
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Related Questions
Correct Answer is B
Explanation
The charge nurse should include the statement "The final step in delegation is evaluation of the outcomes" in the teaching. This is because it is important for the nurse to evaluate the outcomes of delegated tasks to ensure that they have been completed correctly and that the client's needs have been met.
Option A is incorrect because it is not the AP's responsibility to document the client's outcome for a delegated task.
Option C is incorrect because a delegated task should have predictable outcomes.
Option D is incorrect because the nurse does not give up accountability for client outcomes when care is delegated. The nurse remains accountable for ensuring that the delegated task is completed correctly and that the client's needs are met.
Correct Answer is B
Explanation
If a float nurse is given a client assignment that requires the use of unfamiliar skills and techniques, the appropriate action for the nurse to take is to request that the charge nurse modify the assignment. This will allow the nurse to provide safe and competent care to their clients.
Option A is incorrect because providing client care as assigned without the necessary skills and knowledge could compromise client safety.
Option C is incorrect because making a formal complaint to the nursing manager is not an immediate solution to the issue at hand.
Option D is incorrect because asking another nurse to trade assignments may not be feasible or appropriate.
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