A nurse is preparing to delegate tasks to an assistive personnel after receiving change-of-shift report. The nurse should assign the AP to obtain vital signs from which of the following clients?

A client who has just returned from the PACU

A client who has a blood pressure of 110/68 mm Hg

A client who is experiencing chest pain

A client who has a fasting blood glucose of 104 mg/dL

Answer and Explanation

The Correct Answer is B

a. A client who has just returned from the PACU:

Vital signs for a client who has just returned from the Post-Anesthesia Care Unit (PACU) are usually obtained by licensed nursing staff due to the potential for complications and the need for close monitoring.

b. A client who has a blood pressure of 110/68 mm Hg:

This client has stable vital signs, and obtaining blood pressure measurements within normal range is a routine task suitable for delegation to assistive personnel.

c. A client who is experiencing chest pain:

Clients experiencing chest pain require immediate assessment by licensed nursing staff or a healthcare provider. This is not a task appropriate for delegation to assistive personnel.

d. A client who has a fasting blood glucose of 104 mg/dL:

Monitoring blood glucose levels is typically within the scope of licensed nursing staff. Delegating tasks related to clients with diabetes or glucose monitoring to assistive personnel may not be appropriate.

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Correct Answer is C

Explanation

a. Providing a 10-minute rest period prior to meals:

This action is not specifically related to feeding technique for clients with dysphagia. While providing a rest period before meals may be beneficial for some clients, especially those who experience fatigue or dyspnea, it is not a standard technique for managing dysphagia during mealtime.

b. Elevating the head of the client’s bed to 30 degrees during mealtime:

The head of the bed should be elevated to at least 45–90 degrees during meals to minimize the risk of aspiration. A 30-degree elevation is insufficient for safe swallowing and increases the likelihood of aspiration.

c. Instructing the client to place her chin toward her chest when swallowing:

This technique, known as the chin-tuck maneuver, helps reduce the risk of aspiration in clients with dysphagia by improving airway protection and directing food and liquid down the esophagus instead of the trachea. It is a widely recommended method to promote safe swallowing.

d. Withholding fluids until the end of the meal:

Fluids should not be withheld until the end of the meal as they are often necessary to help the client swallow food safely and prevent choking. Thickened fluids may be prescribed for clients with dysphagia to aid in safe swallowing.

A. Decreased level of consciousness B. Increased temperature C. Generalized rash over trunk D. Report of photophobia

Correct Answer is A

Explanation

a. Decreased level of consciousness:

This finding is concerning and may indicate worsening neurological status, increased intracranial pressure, or impending herniation. A decreased level of consciousness requires immediate evaluation by the provider to assess for neurological deterioration and potential interventions to stabilize the client's condition.

b. Increased temperature:

While an increased temperature (fever) is commonly associated with meningitis due to the inflammatory response, it may not necessarily require immediate reporting unless it is extremely high or accompanied by other concerning symptoms. Fever management is important, but it may not warrant immediate provider notification unless it is severe or refractory to treatment.

c. Generalized rash over trunk:

A generalized rash can be associated with certain types of meningitis, such as meningococcal meningitis, and may indicate sepsis or disseminated infection. However, it may not always require immediate provider notification unless it is accompanied by other concerning symptoms or signs of systemic illness.

d. Report of photophobia:

Photophobia (sensitivity to light) is a common symptom of meningitis and is often reported by clients. While photophobia is significant in the context of meningitis, it may not require immediate provider notification unless it is severe or accompanied by other worrisome neurological symptoms.

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A nurse is preparing to delegate tasks to an assistive personnel after receiving change-of-shift report. The nurse should assign the AP to obtain vital signs from which of the following clients?

Nursing Test Bank

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Explanation

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Correct Answer is A

Explanation

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