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
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 D
Explanation
A. Dismissing the client's feelings does not address the client's anxiety.
B. Comparing the client to others does not address her individual concerns and may feel dismissive.
C. Asking "why" questions can come across as judgmental and may not encourage open communication.
D. Encouraging the client to express her concerns is a therapeutic communication technique that validates her feelings and can help reduce anxiety.
Correct Answer is B
Explanation
A. Stage 1 hypertension is defined as a systolic BP of 130-139 mm Hg or a diastolic BP of 80-89 mm Hg.
B. Elevated BP is defined as a systolic BP of 120-129 mm Hg and a diastolic BP of less than 80 mm Hg.
C. Stage 2 hypertension is defined as a systolic BP of 140 mm Hg or higher or a diastolic BP of 90 mm Hg or higher.
D. Normal BP is defined as a systolic BP of less than 120 mm Hg and a diastolic BP of less than 80 mm Hg.
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