A client with delusions tells the nurse, "You aren't doing your job.
Go get those people over there and shoot them before they get me." Which statement is the nurse's best response?

Choice A rationale:

Assigning a client who is one day postoperative for a laparoscopic cholecystectomy to the practical nurse (PN) is appropriate. This procedure is minimally invasive, and the client is likely stable, requiring routine postoperative care such as wound assessment, pain management, and monitoring for any signs of complications.

Choice B rationale:

An older client who is one day postoperative with a colostomy for colon cancer may have complex postoperative needs, including colostomy care, monitoring for complications, and pain management. This level of care is usually within the scope of the registered nurse (RN) rather than a practical nurse (PN).

Choice C rationale:

An older adult who is scheduled for foot amputation due to diabetes complications is likely to have complex care needs, including wound care, diabetes management, and potential complications. This client would require the expertise of an RN rather than a PN.

Choice D rationale:

An adult with alcoholism, cirrhosis, and hepatic encephalopathy may have complex medical and psychosocial issues that require specialized nursing care. This client's condition is not appropriate for a practical nurse (PN) to manage, and the care should be provided by an RN or other specialized healthcare provider.

The correct answer is Choice D.

Choice A rationale: Moving Client D into an isolation room 24 hours before surgery is not necessary. The client’s white blood cell (WBC) count is 14,000 mm (14 x 10^9/L), which is higher than the normal range of 5000 to 10,000/mm² (5 to 10 x 10^9/L). This indicates that the client may have an infection. However, it is not standard practice to isolate clients scheduled for surgery based solely on an elevated WBC count. Other factors, such as the presence of specific infectious diseases, would dictate the need for isolation.

Choice B rationale: Asking the dietitian to add a banana to Client C’s breakfast tray is not necessary. The client’s potassium level is 3.8 mEq/L (3.8 mmol/L), which is within the normal range of 3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L). Therefore, there is no need to increase the client’s potassium intake.

Choice C rationale: Increasing Client A’s oxygen to 4 liters a minute per cannula is not necessary. The client has emphysema and their oxygen saturation is 94%, which is within the normal range. Increasing the oxygen flow rate could lead to oxygen toxicity or suppress the client’s respiratory drive, leading to respiratory depression or failure.

Choice D rationale: Verifying that Client B has two units of packed cells available is the correct intervention. The client’s postoperative hemoglobin level is 8.2 mg/dL (82 g/L), which is lower than the normal range of 14 to 18 g/dL (140 to 180 g/L). This indicates that the client is anemic and may require a blood transfusion. Therefore, it is important to ensure that packed cells are available if needed.