A nurse is delegating tasks to an assistive personnel (AP). For which of the following clients should the nurse have the AP measure vital signs?
A client who has a new onset of weakness
A client who is requesting pain medication 2 days after surgery
A client who has a new onset of chest pain
A client who is transferring to the intensive care unit
The Correct Answer is B
Choice A reason: A new onset of weakness requires nursing assessment because it could indicate an acute change in condition such as stroke, electrolyte imbalance, or infection. Delegating vital signs in this case would be unsafe, as the nurse must perform a thorough assessment and determine appropriate interventions.
Choice B reason: A client requesting pain medication 2 days after surgery is stable enough for the AP to measure vital signs. This task is appropriate to delegate because the nurse can then use the vital signs to evaluate the client’s status before administering pain medication. The nurse retains responsibility for interpreting the results and deciding on medication administration, but the AP can safely collect the data.
Choice C reason: A new onset of chest pain is a potentially life-threatening emergency that requires immediate nursing assessment and intervention. Delegating vital signs in this situation would delay critical care. The nurse must personally assess the client, obtain vital signs, and initiate emergency protocols if necessary.
Choice D reason: A client transferring to the intensive care unit is unstable and requires close monitoring. The nurse must perform a comprehensive assessment and obtain vital signs themselves to ensure accurate evaluation before and during transfer. Delegating this task would be inappropriate because of the client’s critical condition.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Extending the legs above heart level is not appropriate for dehiscence. This position does not reduce intra-abdominal pressure or protect the incision site.
Choice B reason: Placing the client in a low-Fowler’s position with knees slightly flexed reduces tension on the abdominal incision. This position minimizes strain, prevents further separation, and promotes comfort. It is the most appropriate immediate action.
Choice C reason: The Valsalva maneuver increases intra-abdominal pressure, which would worsen dehiscence and potentially lead to evisceration. It is contraindicated.
Choice D reason: Applying a dry gauze dressing does not provide adequate protection. A sterile, moist dressing is preferred to prevent tissue drying and reduce infection risk. Dry gauze could adhere to exposed tissue and cause trauma upon removal.
Correct Answer is D
Explanation
Choice A reason: Cleansing wounds with povidone-iodine on cotton balls is not recommended because it can damage granulation tissue and delay healing. Cotton fibers may also remain in the wound, increasing infection risk.
Choice B reason: Administering analgesia prior to irrigation is appropriate for pain management but does not directly demonstrate correct irrigation technique. While important, it is not the best indicator of proper wound irrigation practice.
Choice C reason: Warming irrigation solution in the microwave is unsafe because it can cause uneven heating and burns. Solutions should be warmed to room temperature using safe methods, not microwaves.
Choice D reason: Irrigating from the cleanest to the most contaminated area is the correct technique. This prevents the spread of microorganisms from contaminated areas into clean tissue, promoting healing and reducing infection risk.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.