A nurse is supervising a newly licensed nurse who is caring for a client on a behavioral health unit.

Exhibits

Complete the following sentence by using the list of options.

The nurse should instruct the newly licensed nurse to first

dropdown

then

dropdown

.

Rationale:

A. A client who is 3 days postoperative following a craniotomy requires careful monitoring due to potential complications from brain surgery, so vital signs should be taken by a nurse.

B. A client who is 3 days postoperative following gastric bypass surgery is stable enough for an AP to obtain vital signs, as the risk of immediate postoperative complications is lower compared to more recent surgeries.

C. A client who is 2 hr postoperative following an abdominal hysterectomy requires close monitoring due to the recent surgery, so vital signs should be obtained by a nurse.

D. A client who is 1 hr postoperative following a thyroidectomy requires vigilant monitoring for potential complications from recent surgery, which should be done by a nurse.

Rationale:

A. Reporting the observation to the nurse caring for that client is important but not the immediate priority.

B. Informing the nursing supervisor is necessary but should be done after assessing the situation directly.

C. Approaching the man and asking why he is making copies is the most immediate and direct action. It allows the nurse to assess the situation and determine if the man has legitimate access to the client's medical record or if further action is needed.

D. Notifying hospital security may be necessary if the man’s actions are unauthorized, but the first step is to gather more information.