A nurse and an assistive personnel (AP) are caring for a client who requests a PRN pain medication. After the nurse administers the medication, which of the following tasks should the nurse assign to the AP?
Document the client's respiratory rate in 1 hr.
Monitor the client for an allergic reaction for 30 min.
Check the client's response to the medication in 1 hr.
Evaluate the client for therapeutic effects in 30 min.
The Correct Answer is A
A. Documenting the client's respiratory rate in 1 hour is within the scope of practice for an assistive personnel (AP) and does not require nursing judgment or assessment.
B. Monitoring the client for an allergic reaction for 30 minutes requires nursing judgment and assessment skills to recognize signs and symptoms of allergic reactions.
C. Checking the client's response to the medication in 1 hour requires nursing judgment and assessment skills to evaluate pain relief and any adverse effects.
D. Evaluating the client for therapeutic effects in 30 minutes requires nursing judgment and assessment skills to determine the effectiveness of the pain medication.
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Related Questions
Correct Answer is D
Explanation
A. While reminders of behavioral expectations can be helpful, excessive verbal guidance may increase frustration and is less effective than physical outlets for excess energy.
B. Group activities can be overstimulating for a client experiencing mania and may escalate agitation or distractibility.
C. Allowing unrestricted clothing choices is not a priority intervention during mania and does not address safety or energy management.
D. Encouraging the client to increase physical activity provides a safe outlet for excessive energy, reduces tension, and helps prevent injury or destructive behaviors. Structured physical activity is a therapeutic strategy during manic episodes.
Correct Answer is D
Explanation
Rationale for A: Delegating complicated tasks to an RN might not always be appropriate, especially if the task falls within the scope of the newly licensed nurse. Time management involves prioritizing and organizing tasks effectively, not shifting responsibility unnecessarily.
Rationale for B: Documenting all client care at the end of the shift can lead to missed or inaccurate documentation. It is more efficient to document in real-time or shortly after completing tasks, ensuring accuracy and preventing a backlog of work.
Rationale for C: Performing quick tasks before time-consuming ones may lead to neglecting critical or urgent tasks. Time-consuming tasks might be of higher priority and should be addressed based on urgency rather than the time they take.
Rationale for D: Completing one task before moving on to the next allows the nurse to focus on each task fully, reducing the chance of errors and ensuring that all tasks are completed systematically. This approach improves efficiency and task management.
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