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 A
Explanation
The nurse should request the client's son, who has a durable power of attorney, to sign the client's informed consent. A durable power of attorney is a legal document that allows an individual to appoint someone to make decisions on their behalf in the event that they become unable to do so. If the client has dementia and is unable to provide informed consent for the procedure, the individual with a durable power of attorney has the legal authority to make decisions on their behalf.
The other individuals are not the appropriate person to sign the client's informed consent. The client's sister [b] and daughter [c] may be involved in the client's care and decision-making, but they do not have the legal authority to provide informed consent on behalf of the client unless they have been designated as such in a legal document. Advance directives [d] are legal documents that allow individuals to communicate their wishes about medical treatment and end-of-life care, but they do not grant decision-making authority to another individual.
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.
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