In which situation is it most appropriate for a nurse to delegate the task of taking vital signs to assistive personnel?
A client who is post-operative day one from a major surgery.
A client experiencing chest pain.
A client receiving blood transfusion.
A stable client in a long-term care facility.
The Correct Answer is D
A. A post-operative day one client requires close monitoring by licensed nursing staff due to the risk of complications; vital signs in this situation are not appropriate to delegate.
B. A client experiencing chest pain requires immediate assessment and intervention by a nurse; delegating vital signs could delay recognition of life-threatening changes.
C. A client receiving a blood transfusion needs continuous monitoring by a nurse to detect adverse reactions; vital signs should not be delegated.
D. A stable client in a long-term care facility has predictable and low-risk needs, making it appropriate to delegate vital signs to assistive personnel.
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Related Questions
Correct Answer is C
Explanation
A. Reassessing the temperature after 2 hours delays intervention and may allow the fever to worsen or cause discomfort to the client.
B. Placing the client in a warm blanket would increase body temperature further and is inappropriate when the client is febrile.
C. Administering antipyretics as prescribed is the most appropriate intervention to help reduce fever, relieve discomfort, and prevent complications associated with elevated body temperature, such as dehydration or tachycardia.
D. Encouraging the client to drink cold water may provide temporary relief, but it does not actively treat the fever or address the underlying cause.
Correct Answer is B
Explanation
A. Cyanosis is an objective finding that the nurse can observe visually during the physical assessment. It indicates reduced oxygenation in the blood and can be measured or confirmed through clinical evaluation, making it a reliable, observable sign.
B. Nausea is subjective data because it is based on the client’s personal experience and self-report. It cannot be directly observed, measured, or verified by the nurse through examination alone. Subjective data are crucial for understanding the client’s symptoms, concerns, and overall perception of health, guiding further assessment and care planning.
C. Petechiae are observable, objective findings, identifiable through visual inspection. They provide measurable signs of possible underlying conditions, such as bleeding disorders or infection.
D. Blood pressure is a quantifiable, objective measurement obtained using a sphygmomanometer. It provides concrete data on the client’s cardiovascular status and is independent of the client’s perception.
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