A nurse is assisting with the care of a group of pediatric clients. Which of the following actions should the nurse take first?
Deliver a breakfast tray to a child who has been administered regular insulin.
Complete pin site care for a child who is in skeletal traction.
Provide clear liquids to a child who is 4 hr postoperative following a laparoscopic appendectomy.
Administer acetaminophen to a child who has a temperature of 101.2°F (38.4°C).
The Correct Answer is A
If a nurse is assisting with the care of a group of pediatric clients, the first action the nurse should take is to deliver a breakfast tray to a child who has been administered regular insulin. This is because regular insulin is a fast-acting insulin that begins to lower blood sugar levels within 15 minutes of administration. It is important for the child to eat shortly after receiving regular insulin to prevent hypoglycemia.
Option B is incorrect because completing pin site care for a child who is in skeletal traction is not as time-sensitive as delivering a breakfast tray to a child who has been administered regular insulin.
Option C is incorrect because providing clear liquids to a child who is 4 hr postoperative following a laparoscopic appendectomy is not as time-sensitive as delivering a breakfast tray to a child who has been administered regular insulin.
Option D is incorrect because administering acetaminophen to a child who has a temperature of 101.2°F (38.4°C) is not as time-sensitive as delivering a breakfast tray to a child who has been administered regular insulin.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","D","E"]
Explanation
The correct answers are Choices A, D, and E.
Choice A rationale:Providing postmortem care to a client who has just passed away is a task that can be delegated to assistive personnel (AP). Postmortem care involves cleaning and preparing the body after death and is not a task that requires the specialized skills or judgement of a nurse. It is important to note that while the physical task of postmortem care can be delegated, the nurse is still responsible for providing emotional support and information to the family, coordinating with the morgue or funeral home, and completing any required documentation.
Choice B rationale:Instructing a client about the use of a spirometer is not a task that should be delegated to assistive personnel. Patient education requires assessment and evaluation of the patient’s understanding, which are nursing responsibilities. A spirometer is a medical device used to measure lung function and is often used after surgery to help prevent complications like pneumonia. Proper use of the spirometer is crucial to its effectiveness, so it is important that the instruction is clear and understood by the patient.
Choice C rationale:Suctioning a client’s newly inserted tracheostomy is not a task that should be delegated to assistive personnel. Tracheostomy care, especially suctioning, requires specialized skills and knowledge, as well as the ability to assess the patient’s respiratory status. Improper suctioning can cause trauma to the trachea, hypoxia, or infection. Therefore, this task should be performed by a nurse or other licensed healthcare professional.
Choice D rationale:Transferring a client to radiology for x-rays is a task that can be delegated to assistive personnel. This task involves physical assistance and does not require specialized nursing skills or judgement. However, the nurse should provide the AP with any necessary information about the patient’s condition, mobility, and any precautions that need to be taken during the transfer.
Choice E rationale:Performing a simple dressing change on a client’s arm is a task that can be delegated to assistive personnel. This task involves changing the bandages on a wound, which is a task that does not require specialized nursing skills or judgement. However, the nurse should ensure that the AP has been properly trained in dressing changes, understands the importance of infection control, and knows when to report any changes in the wound’s appearance.
Correct Answer is D
Explanation
If a nurse overhears two assistive personnel (AP) discussing a client who is currently hospitalized in the hospital cafeteria, the appropriate action for the nurse to take is to quietly tell the APs that the conversation is inappropriate. This will allow the nurse to address the issue in a respectful and professional manner and remind the APs of their responsibility to maintain client confidentiality.
Option A is incorrect because completing an incident report may be necessary, but it should not be the first action taken.
Option B is incorrect because reporting the incident to the provider is not an appropriate action in this situation.
Option C is incorrect because documenting the occurrence in the client's medical record is not an appropriate action in this situation.
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