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 D
Explanation
a. A client is refusing care from assistive personnel of the opposite gender:
This situation involves the client's right to refuse care based on personal preferences or cultural beliefs. While it requires attention and respect for the client's wishes, it may not pose an immediate risk to patient care or staff safety.
b. No transport assistance is available to take a client to physical therapy:
This can be resolved by contacting the transportation department or finding an alternative solution, but it is not a critical issue that requires immediate attention.
c. Two nurses had a heated disagreement about a scheduling issue:
While workplace conflicts should be addressed to promote a positive work environment, a heated disagreement about a scheduling issue may not pose an immediate threat to patient care. However, if the disagreement escalates or affects staff morale, it could impact unit functioning and require intervention.
d. Three staff members have called to say they will be absent:
This situation has the most immediate impact on the overall functioning of the unit. Staffing shortages can affect patient care and safety, so it is crucial to address this issue promptly to ensure adequate coverage and maintain the quality of care.
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.
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