Which information will the nurse consider when deciding what nursing actions to delegate to a licensed practical/vocational nurse (LPN/VN) who is working on a medical-surgical unit?

Choice A: Collect patient information

This is the first step in the nursing process, known as the assessment phase. During this phase, the nurse gathers comprehensive information about the patient’s health status, including medical history, physical examination findings, and any relevant diagnostic test results. This information forms the foundation for identifying the patient’s health needs and planning appropriate care.

Choice B: Identify any clinical problems

The second step is the diagnosis phase, where the nurse analyzes the collected data to identify the patient’s health problems. These problems can be actual or potential issues that require nursing intervention. Accurate identification of clinical problems is crucial for developing an effective care plan.

Choice C: Decide a plan of action

The third step is the planning phase. In this phase, the nurse sets measurable and achievable goals for the patient’s care and decides on the appropriate nursing interventions to address the identified clinical problems. The plan of action should be individualized to meet the specific needs of the patient.

Choice D: Carry out the plan

The fourth step is the implementation phase, where the nurse executes the planned interventions. This may involve administering medications, providing education, performing procedures, or coordinating with other healthcare professionals. The goal is to achieve the desired patient outcomes as outlined in the care plan.

Choice E: Determine whether the plan was effective

The final step is the evaluation phase. In this phase, the nurse assesses the patient’s response to the implemented interventions and determines whether the goals of the care plan have been met. If the desired outcomes are not achieved, the nurse may need to revise the care plan and repeat the process.

Choice A: Bradypnea

Bradypnea, or slow breathing, is not typically associated with inadequate pain control. It is more often related to the effects of certain medications, such as opioids, or underlying respiratory conditions. Inadequate pain control is more likely to cause increased respiratory rate (tachypnea) rather than decreased.

Choice B: Irritability

This is a correct answer. Irritability can be a sign of inadequate pain control. Pain can cause significant discomfort and distress, leading to changes in mood and behavior. Patients who are in pain may become irritable, anxious, or agitated.

Choice C: Tachycardia

This is another correct answer. Tachycardia, or an increased heart rate, can be a physiological response to pain. When a patient is in pain, the body’s stress response is activated, leading to the release of stress hormones like adrenaline, which can increase heart rate.

Choice D: Hypoglycemia

Hypoglycemia, or low blood sugar, is not directly related to pain control. It is more commonly associated with diabetes management, fasting, or certain medications. While it is important to monitor blood sugar levels, hypoglycemia is not a typical indicator of inadequate pain control.

Choice E: Poor cough effort

This is a correct answer. Poor cough effort can indicate inadequate pain control, especially after chest surgery. Pain can make it difficult for patients to take deep breaths or cough effectively, which is essential for preventing respiratory complications such as pneumonia.

Choice F: Drowsiness

Drowsiness is not typically a sign of inadequate pain control. It is more often a side effect of pain medications, particularly opioids. While it is important to monitor for excessive sedation, drowsiness alone does not indicate that pain is not being adequately managed.

Choice G: Refusal to participate in physical therapy

This is the final correct answer. Refusal to participate in physical therapy can be a sign of inadequate pain control. Pain can make movement and physical activity difficult and uncomfortable, leading patients to avoid necessary rehabilitation exercises. Effective pain management is crucial for encouraging participation in physical therapy and promoting recovery.