The nurse and unlicensed assistive personnel (UAP) on the telemetry unit are caring for four clients. Which nursing action can be delegated to the UAP?
Checking the client's catheter site after a coronary angiogram
Teaching a patient about exercise electrocardiography
Attaching ECG monitoring electrodes after a patient bathes
Monitoring a client after a transesophageal echocardiogram
The Correct Answer is D
Monitoring a client after a transesophageal echocardiogram involves observing the client for any immediate post-procedure complications or adverse reactions. This may include assessing vital signs, monitoring for signs of bleeding or infection, and reporting any concerning symptoms or changes in the client's condition to the nurse.
Checking the client's catheter site after a coronary angiogram requires assessing the site for bleeding, hematoma, or signs of infection. This task involves more complex assessment skills and would typically be performed by the nurse.
Teaching a patient about exercise electrocardiography involves providing education on the purpose of the test, the procedure itself, and any preparation or precautions the patient needs to take. This task requires specialized knowledge and is best performed by the nurse who can address the patient's specific questions and concerns.
Attaching ECG monitoring electrodes after a patient bathes requires technical knowledge and skill in properly placing the electrodes and ensuring accurate ECG readings. This task also falls within the scope of the nurse's responsibilities.
Delegation should be based on the UAP's skill set, training, and the complexity of the task. While the UAP can provide valuable support in monitoring a client after a transesophageal echocardiogram, the other tasks mentioned require the expertise and knowledge of a nurse.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Based on the information provided, the nurse should anticipate that the medical treatment prescribed for a client with an abdominal aortic aneurysm less than 3 cm in size would be regular ultrasound screenings every six (6) months.
Monitoring the size of the abdominal aortic aneurysm through ultrasound is a common approach for managing small aneurysms. Regular ultrasound screenings allow healthcare providers to track the growth rate of the aneurysm and determine if any intervention, such as surgical repair, is necessary as the aneurysm progresses in size.
Let's review the other options and explain why they are not the most appropriate treatments for an abdominal aortic aneurysm less than 3 cm in size:
Intravenous pyelogram yearly: An intravenous pyelogram is an imaging test used to evaluate the urinary system, specifically the kidneys, ureters, and bladder. It is not directly related to the management or monitoring of an abdominal aortic aneurysm.
Assessment of abdominal girth monthly: Assessing the abdominal girth may be a part of the overall assessment of the client's condition, but it is not the primary treatment for managing an abdominal aortic aneurysm. Monitoring the aneurysm size through regular ultrasound screenings is a more specific and accurate approach.
Repair of abdominal aortic aneurysm: Repair of an abdominal aortic aneurysm is typically indicated when the aneurysm reaches a certain size threshold or if it poses a high risk of rupture. For an aneurysm less than 3 cm in size, repair is usually not the initial treatment option. Instead, regular monitoring through ultrasound screenings is recommended to assess the aneurysm's growth rate and determine the appropriate time for intervention.
Correct Answer is D
Explanation
"Have you recently taken any antihistamines?": This question is not directly related to the client's high blood pressure. Antihistamines are medications used to treat allergic reactions and have minimal impact on blood pressure.
"Have there been recent stressful events in your life?": Stress can affect blood pressure levels, so this question is relevant. Stressful events can trigger temporary increases in blood pressure. However, it is important to note that consistently high blood pressure readings require medical attention beyond stress management alone.
"Did you take any acetaminophen today?": Acetaminophen (also known as paracetamol) is a pain reliever and fever reducer. It does not have a significant impact on blood pressure levels. Therefore, this question may not directly address the issue of high blood pressure.
"Have you consistently taken your medications?" : This question is the most appropriate follow-up question for a client with a history of high blood pressure. It addresses medication adherence, which is crucial for managing hypertension. The client's blood pressure reading of 210/106 mm Hg suggests that their current medication regimen may not be effectively controlling their blood pressure. Assessing medication consistency will help determine if the elevated blood pressure is due to non-adherence or if a change in medication is required.
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