A nurse in the medical-surgical unit is assigning client care to a nurse who is floating from the PACU. The nurse should recognize that the float nurse is most qualified to care for which of the following clients?

A client who is being discharged to a long-term care facility

A client who is postoperative following a lobectomy and has a chest tube

A client who needs teaching about insulin self-administration

A client who needs teaching prior to initiating cardiac rehabilitation activities

Answer and Explanation

The Correct Answer is B

A. A client being discharged to a long-term care facility may need comprehensive discharge planning, which involves familiarity with long-term care requirements, but this is not typically within the primary expertise of a PACU nurse.
B. A client who is postoperative following a lobectomy and has a chest tube falls within the PACU nurse's area of expertise. PACU nurses are experienced in monitoring and managing postoperative clients, including those with chest tubes, as these clients require close monitoring for complications such as respiratory distress or chest tube malfunction.
C. Teaching about insulin self-administration is important, but this task is more suited to nurses experienced in chronic care management, such as those from medical-surgical or endocrinology units.
D. Teaching prior to initiating cardiac rehabilitation requires specialized knowledge in cardiac care, which may not be the primary focus of a PACU nurse's practice.

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Correct Answer is ["A","B","D","F"]

Explanation

A. Peripheral IV in large vein
Vancomycin should be administered through a large-bore IV to minimize the risk of complications such as phlebitis and to ensure effective drug delivery. This is a key factor in safely administering the medication.
B. Dosage in safe range
Confirming that the dosage is within the safe range ensures that the medication is administered at an effective but non-toxic level. Proper dosing is essential for achieving therapeutic effects without causing harm.
C. No known allergies
Ensuring that the client has no known allergies to vancomycin is critical to prevent allergic reactions. This step is necessary for the safe administration of the antibiotic.
D. Potassium 4.4 mEq/L (4.4 mmol/L)
While normal potassium levels are important for overall health, they do not specifically indicate the safety of vancomycin administration. Other factors such as IV access and dosage are more directly related to the safety of vancomycin.
E. Used for prophylaxis
Vancomycin is used for endocarditis prophylaxis in this case, which aligns with the clinical guidelines for preventing infections. Understanding the purpose of the medication supports its appropriate use in the client’s care.
F. Blood urea nitrogen 17 mg/dL (6.07 mmol/L)
An elevated BUN level might indicate renal impairment, which could affect vancomycin metabolism. However, this level alone does not directly address the immediate safety of administering the antibiotic compared to other factors like IV access and dosage.

A. Provide assistance to bathroom. B. Increase fluids. C. Perform a bladder scan. D. Insert a straight catheter.

Correct Answer is C

Explanation

A. Providing assistance to the bathroom is appropriate but should follow assessment and intervention for urinary retention.
B. Increasing fluids may be beneficial but does not address the immediate need to assess for urinary retention.
C. Performing a bladder scan is the first action to assess if the client has urine in the bladder and needs further intervention.
D. Inserting a straight catheter is a potential intervention but should be based on assessment findings from the bladder scan.

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A nurse in the medical-surgical unit is assigning client care to a nurse who is floating from the PACU. The nurse should recognize that the float nurse is most qualified to care for which of the following clients?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Exhibits The nurse collects blood from the client during peripheral IV line placement. What laboratory specimens would the nurse expect for the provider to order? Select all that apply.

Correct Answer is ["A","B","D","F"]

Explanation

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Correct Answer is C

Explanation

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