A nurse is planning care for a group of clients. The nurse should delegate obtaining vital signs to an assistive personnel for which of the following clients? (Select all that apply.)
A young adult client who is 24 hr postoperative following an appendectomy
A middle adult client who has status asthmaticus
A young adult client receiving a continuous IV infusion of regular insulin for diabetic ketoacidosis
An older adult client who is 36 hr postoperative from a traditional cholecystectomy
An older adult client who has a history of heart failure and is ready for discharge
Correct Answer : A,D,E
Rationale:
A. A young adult client who is 24 hr postoperative following an appendectomy is correct because this client is generally stable, with a routine postoperative course expected. Vital signs at this stage are considered predictable and non-complex, making them appropriate for delegation to an assistive personnel (AP). The AP can accurately measure and record the vitals, while the nurse retains responsibility for interpreting the results and responding to any abnormalities.
B. A middle adult client who has status asthmaticus is incorrect. Status asthmaticus is a life-threatening condition that can deteriorate rapidly. Vital signs in this context are dynamic and critical for clinical decision-making. Only a licensed nurse should obtain and interpret them, as immediate interventions may be required if respiratory status worsens.
C. A young adult client receiving a continuous IV infusion of regular insulin for diabetic ketoacidosis (DKA) is incorrect. Clients in DKA are critically ill, with fluctuating glucose levels, fluid imbalances, and electrolyte disturbances. Vital signs must be obtained by a nurse who can assess trends, correlate findings with lab values, and adjust treatment as needed. Delegating this task to an AP could delay recognition of a potentially life-threatening change.
D. An older adult client who is 36 hr postoperative from a traditional cholecystectomy is correct. Provided the client is stable, pain is controlled, and there are no complications, vital signs are considered routine. The AP can safely obtain and record them, freeing the nurse to focus on more complex tasks, such as assessing surgical sites or managing medications.
E. An older adult client who has a history of heart failure and is ready for discharge is correct. This client is stable and not exhibiting acute symptoms, making routine vital signs appropriate for AP delegation. The nurse retains responsibility for reviewing the vitals, interpreting trends, and providing education prior to discharge.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Rationale:
A. Documenting the error in the medical record but not notifying the patient unless asked is incorrect because veracity requires honesty and transparency. Failing to proactively inform the patient violates ethical principles and can erode trust.
B. Reporting the error only to the healthcare provider and supervisor without informing the patient is incorrect because disclosure to the patient is a moral and legal obligation. Omitting this step prioritizes avoidance of discomfort over patient rights and safety.
C. Waiting to see if the patient experiences adverse reactions is incorrect because it delays disclosure and prevents the patient from making informed decisions about their care. This approach is ethically inappropriate and may increase harm.
D. Immediately informing the patient about the error and explaining potential consequences and next steps is correct. This aligns with the ethical principle of veracity, which obligates nurses to be truthful and transparent. Prompt disclosure maintains trust, allows the patient to participate in decisions about their care, and facilitates timely interventions to prevent or mitigate harm.
Correct Answer is D
Explanation
Rationale:
A. Utility is incorrect because the principle of utility focuses on maximizing overall benefit or the greatest good for the greatest number of people. While utility considers outcomes for many, the nurse’s action here is focused on protecting an individual’s privacy, not on weighing benefits for a group.
B. Justice is incorrect because justice refers to fairness, equity, and impartial treatment in healthcare, including allocation of resources or services. Maintaining the surgeon’s confidentiality is not an issue of equitable distribution or fairness, but rather an ethical responsibility to the individual.
C. Paternalism is incorrect because paternalism involves making decisions for someone else, potentially overriding their autonomy, because you believe it is in their best interest. In this case, the nurse is not making a decision for the surgeon; rather, the nurse is honoring the surgeon’s right to privacy and autonomy regarding personal medical information.
D. Nonmaleficence is correct because nonmaleficence embodies the ethical principle of “do no harm.” By refusing to disclose the surgeon’s medical diagnosis, the nurse is preventing potential harm, which could include professional consequences, discrimination, stigma, or emotional distress. Protecting confidential information is a key way that nurses uphold nonmaleficence, ensuring that their actions do not inflict harm on patients or colleagues.
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