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. Limited social support:

Limited social support can impact the client's ability to manage their recovery and may increase the risk of complications or readmission. However, it may not be the most immediate concern if other issues pose a more significant risk to the client's health and recovery.

b. Decreased self-esteem:

Decreased self-esteem can affect the client's emotional well-being and may impact their motivation to engage in self-care activities. While important to address, it may not have an immediate impact on the client's physical recovery following CABG surgery.

c. Inadequate food supply:

Inadequate food supply can hinder the client's ability to meet their nutritional needs, which are essential for wound healing and overall recovery after surgery. This issue could potentially impact the client's physical recovery and should be addressed promptly.

d. Low pain tolerance:

Low pain tolerance can affect the client's ability to manage postoperative pain and may hinder their participation in activities necessary for recovery, such as mobility and respiratory exercises. Addressing pain management is crucial for promoting the client's comfort and facilitating recovery.

A. You must choose a member of your family to serve as you health care proxy B. A health care proxy can make decisions for you when you are unable to do so C. You should appoint a health care proxy before undergoing an invasive procedure D. It is necessary for an attorney to approve your healthcare proxy

Correct Answer is B

Explanation

a. "You must choose a member of your family to serve as your health care proxy":

This response is not accurate. While family members are often chosen as healthcare proxies, the client is not required to select a family member. The most important consideration is choosing someone who understands the client's healthcare wishes and is willing and able to advocate for them. The nurse should emphasize the importance of selecting a trusted individual, whether they are a family member or not.

b. "A health care proxy can make decisions for you when you are unable to do so":

This response is accurate. A healthcare proxy is a legal document that allows an individual to appoint someone else to make healthcare decisions on their behalf if they become unable to do so due to illness or incapacity. The nurse should explain the role of a healthcare proxy in advocating for the client's wishes and ensuring that their healthcare preferences are honored.

c. "You should appoint a health care proxy before undergoing an invasive procedure":

While it is advisable for clients to have advance directives, including a healthcare proxy, in place before undergoing any medical procedure, this response does not fully address the client's question. The timing of appointing a healthcare proxy should not be limited to specific medical procedures but should be based on the client's readiness to make such decisions and their recognition of the importance of having a designated advocate for their healthcare needs.

d. "It is necessary for an attorney to approve your health care proxy":

This response is not accurate. While it may be helpful to seek legal advice when creating advance directives, including a healthcare proxy, it is not a requirement for an attorney to approve the document. The client can typically complete a healthcare proxy form themselves, following the legal requirements of their jurisdiction. However, consulting with an attorney can provide additional guidance and ensure that the document is properly executed.

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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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