It would be appropriate to delegate the taking of vital signs of which client to unlicensed assistive personnel?
A client being prepared for elective facial surgery with a history of stable hypertension
A client receiving a blood transfusion with a history of transfusion reactions
A client recently started on a new antiarrhythmic agent
A client who is admitted frequently with asthma attacks
The Correct Answer is A
According to the ANA and NCSBN guidelines, UAPs can take vital signs in stable clients, but the nurse is still responsible for interpreting the findings and taking action when needed. For clients who are unstable, newly admitted, or receiving high-risk treatments, vital signs should be taken by the nurse to allow for immediate clinical judgment.
Rationale for correct answer:
A. A client being prepared for elective facial surgery with a history of stable hypertension: This client is clinically stable and undergoing a planned, non-emergency procedure. The history of stable hypertension implies no acute instability, making it appropriate for the UAP to collect vital signs.
Rationale for incorrect answers:
B. A client receiving a blood transfusion with a history of transfusion reactions: This client is high risk due to a known history of transfusion reactions. Vital signs need to be monitored closely and frequently by a licensed nurse who can recognize early signs of a reaction.
C. A client recently started on a new antiarrhythmic agent: Starting a new antiarrhythmic introduces potential for serious adverse effects, including bradycardia, hypotension, or arrhythmias.
D. A client who is admitted frequently with asthma attacks: Although this client may be familiar to the unit, frequent asthma exacerbations place them at risk for acute respiratory deterioration. Vital signs should be taken by the nurse to assess signs of distress.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The American Heart Association recommends selecting a cuff size based on the circumference of the patient’s upper arm, not just age or weight.
Rationale for correct answer:
A. An incorrect reading: Using the wrong cuff size is the most common error in BP measurement. A cuff too small may falsely elevate the BP reading. A cuff too large may falsely lower the reading.
Rationale for incorrect answers:
B. Injury to the patient: While rare, prolonged or repeated inflation could cause discomfort, especially in fragile patients, but injury is uncommon due to cuff size alone.
C. Prolonged pressure on the arm: The duration of pressure is more related to how long the cuff is inflated, not its size.
D. Loss of Korotkoff sounds is typically related to improper stethoscope placement, cuff deflation speed, or poor technique, not cuff size alone.
Take-home points:
- Using the wrong cuff size results in inaccurate BP readings, which may lead to misdiagnosis and improper management.
- Always measure the mid-upper arm circumference and choose a cuff that covers 40% of the arm's width and 80% of its length for accuracy.
Correct Answer is D
Explanation
The hypothalamus is the primary center for thermoregulation. When a client sustains a head injury, especially involving the hypothalamus or brainstem, the body may lose its ability to properly regulate temperature. This can lead to a neurogenic fever, which is a non-infectious fever caused by damage to the thermoregulatory center.
Rationale for correct answer:
D. Ineffective thermoregulation: This nursing diagnosis reflects an actual disruption in temperature regulation due to neurological impairment. It encompasses both fever and hypothermia, making it the most comprehensive and accurate for this client.
Rationale for incorrect answers:
A. Risk for imbalanced body temperature: This diagnosis is used when the risk factors are present, but the condition has not yet occurred.
B. Hyperthermia refers to an elevated body temperature due to external heat or failure of heat loss mechanisms (e.g., heatstroke, environmental exposure).
C. Hypothermia is defined as a core body temperature below 35°C (95°F). There’s no indication that the client is hypothermic, and with the mention of neurogenic fever, the temperature is expected to increase, not decrease.
Take-home points:
- Ineffective thermoregulation is the most appropriate nursing diagnosis for clients with neurologically driven temperature abnormalities, such as neurogenic fever.
- Nurses must differentiate between external causes of hyperthermia and central (neurogenic) causes, especially in clients with head injuries.
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