Exhibits

Lana is developing Mrs. Watson's care plan. She wants to add more interventions and not just deliver pain medication. What are some other nursing actions that would be helpful to Mrs. Watson? Select the 4 correct answers (Case Study #2)

A. Document the findings in the patient's medical record. While documentation is important, further assessment is needed before determining if the blood pressure is abnormal for this patient.
B. Apply a cool washcloth to the patient's forehead. The patient’s temperature is normal (98.9°F), so there is no need for cooling measures.
C. Administer oxygen at 2 L/minute via nasal cannula. The pulse oximetry is 94%, which is adequate for most patients. Oxygen is not needed unless the patient shows signs of respiratory distress.
D. Ask the patient about his usual blood pressure results. The blood pressure (144/94 mmHg) is elevated, but before determining if intervention is needed, the nurse should ask if this is typical for the patient or if it is an isolated finding.

A. The nurse should review the patient's vital signs as soon as they are done. Even though vital signs can be delegated, the nurse retains accountability for assessing the data, interpreting abnormalities, and determining if further action is needed.
B. The nurse assistant should not be responsible for obtaining vital signs. Nurse assistants can take vital signs if they are properly trained and it is within their scope of practice. However, the nurse remains responsible for interpreting and acting on the results.
C. The nurse is not responsible if the nurse assistant fails to obtain the vital signs. The nurse remains accountable for delegated tasks and must ensure they are completed correctly.
D. The nurse assistant should determine if the patient's vital signs are abnormal. Nurse assistants can report abnormal findings, but they are not responsible for interpreting results or making clinical decisions—this is the nurse’s responsibility.