A nurse is delegating care for a client.
Exhibit 1
Nurses' Notes 1000:
Client has right sided weakness following a cerebrovascular accident. Client coughs when eating and voice becomes hoarse after swallowing. Select the 3tasks the nurse should assign to assistive personnel.
Assist the client with completing their food menu.
Document the client's urine output
Monitor the client for manifestations of aspiration pneumonia
initiate a referral with the speech language pathologist E. Instruct the client on swallowing techniques
Ambulate the client.
Obtain the client's vital signs.
Obtain the client's vital signs.
Correct Answer : B,F,G
Role of assistive personnel is activities of daily living, document input and output, obtain stable vitals as well assist clients in ambulating.
A. The choice of food should consider the risk of aspiration and should include soft food. The high-risk client needs the involvement of a nurse
C. Monitoring the client for features of aspiration pneumonia is in the scope of a registered nurse as it requires clinical judgment and knowledge. –
D. Initiating referral to a speech language pathologist is in the scope of a nurse.
E. Instructing on swallowing techniques is an intervention performed by nurses as it requires demonstration of safety techniques.
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Related Questions
Correct Answer is D
Explanation
The client with slurred speech and confusion could be experiencing a stroke. Recognition of a stroke is an emergency as some forms of stroke requires immediate intervention that is only amenable within a specific time period.
A. A closed femur fracture may have bleeding and other neurovascular damage but this is not as life threatening as a stroke
B. Superficial burns of 10% is likely to have severe pain. The extent of dehydration is minimal
C. Severe vomiting and diarrhea with tachycardia is a sign that the body is compensating for the fluid loss at this point and, therefore, not of highest priority.
Correct Answer is D
Explanation
This is important information that should be included in the background section. Understanding a client's code status (e.g., full code, DNR) is critical for the receiving team, as it affects the management and response to the client’s care.
A. Recommendation
B. Assessment
C. While the client's name is important for identification, it is generally considered part of the introduction rather than the background. The background focuses more on medical history and relevant context.
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