A nurse is delegating tasks for an assistive personnel (AP) to perform for a client who is 1-day postoperative following cardiac surgery. Which of the following tasks should the nurse perform herself?

Helping the client into the shower

Ambulating the client in the hallway

Measuring vital signs

Removing the sternal dressing

Answer and Explanation

The Correct Answer is D

A. Helping the client into the shower: This task can be safely delegated to an assistive personnel (AP). The AP can help the client with activities of daily living such as showering, as long as the client is stable and does not require close monitoring.

B. Ambulating the client in the hallway: This task can also be delegated to an AP. Assisting with ambulation is within the scope of practice for an AP, provided the client is stable and there are no specific concerns that require a nurse’s assessment.

C. Measuring vital signs: While measuring vital signs is a critical task, it can be delegated to an AP. The AP can be trained to accurately measure and report vital signs. However, the nurse should review and interpret the results.

D. Removing the sternal dressing: This is the correct answer. Removing a sternal dressing after cardiac surgery is a complex task that requires a nurse’s expertise2. The nurse needs to assess the surgical site for signs of infection or complications, which is beyond the scope of practice for an AP. Therefore, this task should not be delegated and should be performed by the nurse herself

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Correct Answer is A

Explanation

(A) Heart murmur: This is the most appropriate answer. Mitral valve stenosis can cause a heart murmur due to turbulent blood flow across the narrowed mitral valve. This is often heard best at the apex of the heart with the patient in the left lateral decubitus position.

(B) Clubbing of the fingers: Clubbing of the fingers is typically associated with conditions that cause chronic hypoxia, such as lung disease or congenital heart disease. It is not a common finding in mitral valve stenosis.

(C) Bradycardia: Mitral valve stenosis does not typically cause bradycardia. In fact, some patients may have a rapid heart rate (tachycardia) due to atrial fibrillation, which is a common complication of mitral valve stenosis.

(D) Barrel chest: A barrel chest is typically associated with chronic obstructive pulmonary disease (COPD) and is not a common finding in mitral valve stenosis. It refers to a rounded, bulging chest that resembles the shape of a barrel. This occurs due to overinflation of the lungs over a long period of time.

A. "I promise I won't tell anyone about this." B. "Let's discuss what you have told me with your family members." C. "Your family is bad for doing this to you." D. "It is not your fault that this happened."

Correct Answer is D

Explanation

(A) “I promise I won’t tell anyone about this.”: This statement is inappropriate because it is the nurse’s legal and ethical duty to report any suspicion or evidence of child abuse to the appropriate authorities. Keeping the information confidential could potentially endanger the child.

(B) “Let’s discuss what you have told me with your family members.”: This statement could potentially put the child at further risk, especially if the abuser is a family member. The child’s safety is the primary concern, and discussing the abuse with family members without the involvement of child protective services could be harmful.

(c) “Your family is bad for doing this to you.”: This statement is judgmental and unprofessional. It’s important to maintain a neutral stance and focus on the child’s feelings and safety rather than placing blame.

(D) “It is not your fault that this happened.”: This is the most appropriate response. It’s crucial to reassure the child that they are not to blame for the abuse. This can help alleviate feelings of guilt or shame that the child may be experiencing. The nurse should also take steps to ensure the child’s immediate safety and report the abuse to the appropriate authorities.

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A nurse is delegating tasks for an assistive personnel (AP) to perform for a client who is 1-day postoperative following cardiac surgery. Which of the following tasks should the nurse perform herself?

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