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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
a. Review current literature regarding client falls:
This option involves conducting a review of existing research and literature on client falls. Reviewing current literature can provide valuable insights into evidence-based practices and interventions for fall prevention. However, conducting a literature review typically follows problem identification and is part of the process of developing an evidence-based approach to addressing the issue.
b. Implement a fall prevention plan:
Implementing a fall prevention plan involves putting in place strategies and interventions aimed at reducing the risk of falls among clients. While implementing a fall prevention plan is an essential step in addressing the issue, it should be based on a thorough assessment of clients at risk for falls (which comes before planning interventions) to ensure that interventions are targeted and effective.
c. Identify clients who are at risk for falls:
This is the most appropriate first step in the quality improvement process. Identifying clients who are at risk for falls allows healthcare providers to focus interventions on those who are most vulnerable. It involves conducting comprehensive assessments, considering factors such as age, mobility, cognitive status, medications, and history of falls, to determine individual risk levels.
d. Notify staff of the increased fall rate:
While communication with staff about the increased fall rate is important for raising awareness and promoting a culture of safety, it should not be the first action taken in the quality improvement process. Before notifying staff, it's essential to identify clients at risk for falls and develop targeted interventions to address the issue effectively.
Correct Answer is C
Explanation
a. Establishing communication between providers:
Telehealth can facilitate communication between healthcare providers, allowing them to consult, collaborate, and share information about patient care remotely. This includes discussing patient cases, sharing test results, and coordinating treatment plans.
b. Developing client treatment protocols:
While telehealth may involve the use of protocols and guidelines to guide care delivery, its primary objective is to provide healthcare services remotely rather than developing treatment protocols specifically.Treatment protocols are typically established during a comprehensive assessment, which telehealth can be a part of, but it's not the sole purpose of a client call
c. Assessing client needs:
This is a core objective of telehealth. It allows healthcare professionals to evaluate the client's current health status, gather relevant information, and determine the necessary next steps in their care remotely.
d. Providing medication reconciliation:
Telehealth can facilitate medication reconciliation by allowing healthcare providers to review a patient's medication list remotely, update medication records, and reconcile any discrepancies during virtual appointments.
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