The nurse delegates vital signs for a patient to the nurse assistant. What is the nurse's responsibility regarding delegation of this task?
The nurse should review the patient's vital signs as soon as they are done.
The nurse assistant should not be responsible for obtaining vital signs.
The nurse is not responsible if the nurse assistant fails to obtain the vital signs.
The nurse assistant should determine if the patient's vital signs are abnormal.
The Correct Answer is A
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.
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Related Questions
Correct Answer is C
Explanation
A. Narrowing of the inferior vena cava, causing low blood flow and increases in venous pressure resulting in varicosities. The inferior vena cava does not significantly narrow with aging. Varicosities are more commonly due to valve insufficiency in the veins rather than vena cava narrowing.
B. Progressive atrophy of the intramuscular calf veins, causing venous insufficiency. Venous insufficiency is common in older adults, but it is primarily due to valve dysfunction and prolonged venous pressure rather than atrophy of calf veins.
C. Peripheral blood vessels growing more rigid with age, producing a rise in systolic blood pressure. Aging leads to arteriosclerosis, where blood vessels become stiffer, reducing their ability to expand and contract, which contributes to increased systolic blood pressure. This is a well-documented normal physiologic change in older adults.
D. Hormonal changes causing vasodilation and a resulting drop in blood pressure. While some hormonal changes occur with aging, they do not typically lead to significant vasodilation. In fact, the loss of vascular elasticity and autonomic dysfunction can contribute to postural hypotension, but not a generalized drop in blood pressure.
Correct Answer is ["A","B","C","E"]
Explanation
A. Distractions such as music. Music and other distractions, such as guided imagery or television, can help shift the patient's focus away from pain, reducing discomfort and anxiety.
B. Massage. Gentle massage can help promote relaxation, improve circulation, and reduce muscle tension, which may enhance pain relief when used alongside medication.
C. Cold or heat applications. Cold therapy can help reduce inflammation and swelling, while heat therapy can improve blood flow and relax muscles, making them effective in managing arthritis pain and post-surgical discomfort.
D. Vigorous rubbing of the joints. Vigorous rubbing could worsen pain and cause irritation, particularly in a patient with arthritis and post-surgical pain. Gentle approaches are more appropriate.
E. Relaxation techniques. Deep breathing, guided imagery, and progressive muscle relaxation can help lower stress and enhance the body's ability to manage pain.
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