Which four of the patient orders can be delegated to the nursing aide? Select all four that apply.
Insert indwelling urinary catheter.
Monitor IV D5 1/2 NS with 20 mEq KCl at 75 m/hr.
Empty urinary catheter and measure the output.
Collect a stool sample for occult blood testing.
Daily weights.
Notify the MD of any signs of bleeding.
Vital signs every 4 hours.
Correct Answer : C,D,E,G
Choice A reason: Insert indwelling urinary catheter. This task requires clinical judgment, sterile technique, and expertise. It is an invasive procedure that should be performed by a registered nurse or a physician.
Choice B reason: Monitor IV D5 1/2 NS with 20 mEq KCl at 75 m/hr. Monitoring IV fluids and medications involves assessing the patient’s response to treatment, recognizing potential complications, and making clinical decisions. This task requires the expertise of a registered nurse.
Choice C reason: Empty urinary catheter and measure the output. This task can be delegated to a nursing aide as it involves routine measurement and documentation, which does not require clinical judgment. It is a simple procedure that can be safely performed by a trained aide.
Choice D reason: Collect a stool sample for occult blood testing. This is a straightforward task that can be delegated to a nursing aide. It involves collecting and labeling the sample correctly, which does not require advanced clinical skills or judgment.
Choice E reason: Daily weights. This task can be safely delegated to a nursing aide. It involves measuring and recording the patient’s weight, which is a routine procedure and does not require clinical judgment.
Choice F reason: Notify the MD of any signs of bleeding. This task involves assessing the patient for signs of bleeding, which requires clinical judgment and should be performed by a registered nurse. The nurse must determine the significance of the findings and communicate them appropriately to the physician.
Choice G reason: Vital signs every 4 hours. Monitoring vital signs is a routine task that can be delegated to a nursing aide. It involves measuring and recording the patient’s blood pressure, heart rate, respiratory rate, and temperature, which does not require advanced clinical skills.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["C","D","E","G"]
Explanation
Choice A reason: Insert indwelling urinary catheter. This task requires clinical judgment, sterile technique, and expertise. It is an invasive procedure that should be performed by a registered nurse or a physician.
Choice B reason: Monitor IV D5 1/2 NS with 20 mEq KCl at 75 m/hr. Monitoring IV fluids and medications involves assessing the patient’s response to treatment, recognizing potential complications, and making clinical decisions. This task requires the expertise of a registered nurse.
Choice C reason: Empty urinary catheter and measure the output. This task can be delegated to a nursing aide as it involves routine measurement and documentation, which does not require clinical judgment. It is a simple procedure that can be safely performed by a trained aide.
Choice D reason: Collect a stool sample for occult blood testing. This is a straightforward task that can be delegated to a nursing aide. It involves collecting and labeling the sample correctly, which does not require advanced clinical skills or judgment.
Choice E reason: Daily weights. This task can be safely delegated to a nursing aide. It involves measuring and recording the patient’s weight, which is a routine procedure and does not require clinical judgment.
Choice F reason: Notify the MD of any signs of bleeding. This task involves assessing the patient for signs of bleeding, which requires clinical judgment and should be performed by a registered nurse. The nurse must determine the significance of the findings and communicate them appropriately to the physician.
Choice G reason: Vital signs every 4 hours. Monitoring vital signs is a routine task that can be delegated to a nursing aide. It involves measuring and recording the patient’s blood pressure, heart rate, respiratory rate, and temperature, which does not require advanced clinical skills.
Correct Answer is A,D,B,E,C,F,G,H,I
Explanation
- Ensure MDHCP has discussed risks and benefits of blood transfusion. (a)
- Educate patient on signs and symptoms of transfusion reaction. (d)
- Obtain cross match and send it to blood bank. (b)
- Gain blood from bank, confirm correct patient, correct product, correct cross match with 2 RNs. (e)
- Initiate transfusion through a large gauge IV per hospital protocol. (c)
- Start transfusion slowly for the first 15 minutes and stay with patient for the first 15 minutes. (f)
- Increase rate of transfusion and monitor patient frequently. (g)
- Ensure transfusion is complete within 4 hours of starting. (h)
- Continue to monitor patient for transfusion reaction for 24 hours following transfusion. (i)
Rationale:
- Ensure MDHCP has discussed risks and benefits of blood transfusion: It's essential that the healthcare provider discusses with the patient the potential risks and benefits of receiving a blood transfusion. This step is crucial for informed consent.
- Educate patient on signs and symptoms of transfusion reaction: Before starting the transfusion, the patient should be educated on what signs and symptoms to watch out for that might indicate an adverse reaction, such as fever, chills, hives, or shortness of breath.
- Obtain cross match and send it to blood bank: A blood sample is taken from the patient to determine their blood type and to perform a crossmatch, which ensures that the donor blood is compatible with the patient's blood.
- Gain blood from bank, confirm correct patient, correct product, correct cross match with 2 RNs: Once the blood is ready, two registered nurses (RNs) will verify the patient's identity, the blood product, and the crossmatch results to ensure everything is correct before proceeding.
- Initiate transfusion through a large gauge IV per hospital protocol: The blood transfusion is started using a large gauge intravenous (IV) line, as per hospital protocols to ensure proper flow and reduce complications.
- Start transfusion slowly for the first 15 minutes and stay with patient for the first 15 minutes: The transfusion is started at a slow rate to monitor for any immediate adverse reactions. The healthcare provider stays with the patient during this time to closely observe them.
- Increase rate of transfusion and monitor patient frequently: If no adverse reactions are noted in the first 15 minutes, the rate of transfusion can be increased. The patient is monitored frequently throughout the transfusion for any signs of a reaction.
- Ensure transfusion is complete within 4 hours of starting: Blood products should be transfused within 4 hours to minimize the risk of bacterial growth and to ensure the effectiveness of the transfusion.
- Continue to monitor patient for transfusion reaction for 24 hours following transfusion: After the transfusion is complete, the patient is monitored for at least 24 hours for any delayed transfusion reactions, such as fever, allergic reactions, or other complications.
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