The nurse is caring for a group of clients with the help of a practical nurse (PN). Which nursing action(s) should the nurse assign to the PN? (Select all that apply)
Obtain postoperative vital signs for a client one day following unilateral knee arthroplasty.
Perform daily surgical dressing change for a client who had an abdominal hysterectomy.
Initiate patient controlled analgesia (PCA. pumps for two clients immediately postoperatively.
Start the second blood transfusion for a client twelve hours following a below knee amputation.
Monitor a dose of warfarin per protocol for a client with type 2 diabetes mellitus (DM).
Correct Answer : A,B,E
Choice C reason: Initiating patient controlled analgesia (PCA. pumps for two clients immediately postoperatively is not a nursing action that can be assigned to the PN. PCA pump is a device that allows the client to self-administer pain medication through an IV line by pressing a button. PCA pump should be initiated by the nurse after verifying the prescription, setting the parameters, educating the client, and ensuring safety and effectiveness. The PN does not have the authority or competency to initiate PCA pump or adjust its settings.
Choice D reason: Starting the second blood transfusion for a client twelve hours following a below knee amputation is not a nursing action that can be assigned to the PN. Blood transfusion is a procedure that delivers donated blood or blood products into the client's bloodstream through an IV line. Blood transfusion should be started by the nurse after verifying the prescription, checking the blood type and compatibility, obtaining informed consent, and monitoring for any adverse reactions. The PN does not have the authority or competency to start blood transfusion or manage its complications.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice B reason: Elevating the head of the bed to a 45-degree angle is not a sufficient intervention for the nurse to implement before leaving the client. Elevating the head of the bed can help reduce snoring and improve breathing by preventing the tongue and soft palate from falling back and obstructing the airway. However, it may not be enough to prevent apnea episodes in clients with obstructive sleep apnea, especially if they have other risk factors such as obesity, enlarged tonsils, or nasal congestion. The nurse should also use other interventions such as a positive airway pressure device, weight loss, or surgery.
Choice C reason: Removing dentures or other oral appliances is not a relevant intervention for the nurse to implement before leaving the client. Dentures or other oral appliances are devices that replace missing teeth or improve dental alignment. They may help improve speech, chewing, and appearance, but they do not have a direct impact on obstructive sleep apnea. The nurse should instruct the client to remove dentures or other oral appliances before going to bed to prevent discomfort, infection, or damage.
Choice D reason: Lifting and locking the side rails in place is not a necessary intervention for the nurse to implement before leaving the client. Side rails are bars that attach to the sides of the bed frame to prevent falls or injuries. They may provide safety and security for some clients, but they may also pose risks such as entrapment, strangulation, or agitation. The nurse should assess the need for side rails on an individual basis and consider alternative measures such as bed alarms, low beds, or floor mats.
Correct Answer is C
Explanation
Choice A reason: Feeding the infant every 4 hours is not a specific instruction for home phototherapy, which is a treatment that uses blue light to break down excess bilirubin in the skin and blood. However, feeding the infant frequently is important to promote hydration and elimination of bilirubin through urine and stool.
Choice B reason: Performing diaper changes under the light is not a recommended instruction for home phototherapy, which is a treatment that uses blue light to break down excess bilirubin in the skin and blood. The nurse should instruct the parents to turn off the light and cover the infant's eyes with protective goggles or patches during diaper changes to prevent eye damage or irritation.
Choice D reason: Covering with a receiving blanket is not an appropriate instruction for home phototherapy, which is a treatment that uses blue light to break down excess bilirubin in the skin and blood. The nurse should instruct the parents to keep the infant unclothed except for a diaper and eye protection during phototherapy to maximize skin exposure to the light and increase its effectiveness.
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