A nurse is supervising a licensed practical nurse (PN) who is providing care to a client who is postoperative. Which of the following statements by the client requires the nurse to follow up with the PN?
“I have not received any of my medications today.”
“Do you know when I will be going home?”
“I do not know how to make the remote control work.”
“My dressing was changed earlier this morning.”
The Correct Answer is A
A. “I have not received any of my medications today.”
The statement "I have not received any of my medications today" requires follow-up from the nurse because it indicates a potential issue with the client's medication administration. It's important to ensure that the client receives the prescribed medications in a timely manner.
B. “Do you know when I will be going home?”
This is a question about the discharge plan and does not indicate an immediate issue that requires follow-up.
C. “I do not know how to make the remote control work.”
While it's a statement about the client's understanding of the remote control, it is not an urgent matter that requires immediate attention.
D. “My dressing was changed earlier this morning.”
This statement indicates that a care task (dressing change) has been completed and does not suggest a problem that requires urgent follow-up.
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Related Questions
Correct Answer is C
Explanation
A. The AP’s rapport with clients:
While a positive rapport with clients is valuable, it is not a direct factor in determining whether an AP is suitable for a specific task based on the five rights of delegation.
B. The AP’s ability to complete the task without assistance:
The ability to complete a task without assistance is relevant but does not guarantee that the AP has the necessary knowledge and skill for the task. The focus should be on competence rather than independence.
C. The AP has the knowledge and skill to perform the task
When considering the five rights of delegation, one of the crucial factors is ensuring that the assistive personnel (AP) has the knowledge and skill necessary to perform the delegated task safely and effectively. Delegated tasks should align with the AP's competence and training to maintain the safety and well-being of the client.
D. The AP’s ability to prioritize:
Prioritization skills are important for healthcare providers, but the focus of delegation, as per the five rights, is on the AP's competence to perform the specific task.
Correct Answer is B
Explanation
A. Integrity of the dressing:
Dressing integrity is important for wound care, but it is not the top priority when considering the client's immediate postoperative needs.
B. Need for suctioning
Maintaining a patent airway is crucial after a total laryngectomy. The absence of a larynx removes the client's ability to breathe through the nose and mouth, so maintaining a clear airway is a top priority. Suctioning may be necessary to remove secretions and maintain airway patency.
C. Patency of the intravenous line:
Intravenous line patency is important for fluid and medication administration, but it is not the priority when compared to maintaining a clear airway.
D. Level of pain:
Pain management is important for the client's comfort, but it is not the immediate priority compared to ensuring a patent airway following a total laryngectomy.
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