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.
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Related Questions
Correct Answer is ["B","C","E"]
Explanation
Discussing clients at the table in the cafeteria [b], disposing of written report sheets into the facility trash receptacle [c], and sharing a personal password with a coworker [e] are all actions that jeopardize client confidentiality. Client information should be kept private and secure at all times. Discussing clients in public places or disposing of client information in an unsecured manner can result in unauthorized access to confidential information. Sharing personal passwords can also compromise the security of client information.
The other options do not jeopardize client confidentiality. Removing client information from fax machines immediately [a] helps to prevent unauthorized access to confidential information. Giving verbal reports at change of shift in a designated conference room [d] is a standard practice that allows for the secure transfer of client information between healthcare providers.
Correct Answer is D
Explanation
Assistive personnel (AP), also known as unlicensed assistive personnel (UAP), can perform tasks such as assisting with activities of daily living, hygiene, and nutrition, as well as those tasks that support professional nursing assessments ². Providing postmortem care for a client who has died [d] is a task that can be delegated to an AP.
The other options are not tasks that should be delegated to an AP. Educating a client on the use of a blood glucose monitor [a] involves patient education, which is typically the responsibility of a licensed nurse.
Interpreting a client's vital signs [b] involves assessing the client's health status, which is also typically the responsibility of a licensed nurse. Performing a central line dressing change for a client [c] is a complex task that requires specialized knowledge and skills.
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