A nurse is caring for a group of clients. She plans to delegate obtaining morning vital signs to an assistive personnel (AP) on her team. Which of the following actions should the nurse plan to take?

Verify the AP's educational preparation prior to delegating the task.

Observe the AP as she obtains the vital signs of each client.

Determine the time frame the AP should report the results

Ask the AP to take the vital signs of the client returning from surgery first.

Answer and Explanation

The Correct Answer is C

Rationale:

A. Verify the AP's educational preparation prior to delegating the task is unnecessary if the AP has been trained and is competent in the task.

B. Observe the AP as she obtains the vital signs of each client is not required for routine tasks unless there is a concern about performance.

C. Determine the time frame the AP should report the results is crucial for ensuring timely and accurate reporting, which is necessary for effective patient care.

D. Ask the AP to take the vital signs of the client returning from surgery first might not be appropriate without considering the urgency of all clients’ conditions.

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Correct Answer is D

Explanation

Rationale:

A. WBC 6,000/mm³ is within normal range and does not require follow-up.

B. BUN 15 mg/dL is within normal range and does not require follow-up.

C. Hemoglobin 14 g/dL is within normal range for most adults and does not require follow-up.

D. Platelet count 60,000/mm³ is significantly low and requires follow-up as it can increase the risk of bleeding during surgery.

A. A young adult client admitted for acute glomerulonephritis following a viral infection B. A dependent adult admitted for the treatment of a spiral fracture C. A young adult client admitted for asthma and has track marks that may indicate IV drug abuse D. An emancipated minor who has acute appendicitis and wants to leave the facility without treatment

Correct Answer is B

Explanation

Rationale:

A. A young adult client admitted for acute glomerulonephritis following a viral infection does not indicate a mandatory report situation.

B. A dependent adult admitted for the treatment of a spiral fracture suggests potential abuse or neglect. As mandated reporters, nurses are required to report suspicions of abuse or neglect to the appropriate authorities.

C. A young adult client admitted for asthma and has track marks that may indicate IV drug abuse does not necessarily require mandatory reporting unless there is evidence of abuse or harm that needs to be reported.

D. An emancipated minor who has acute appendicitis and wants to leave the facility without treatment may raise concerns about the minor's capacity to make decisions, but it does not automatically necessitate reporting to an outside agency.

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A nurse is caring for a group of clients. She plans to delegate obtaining morning vital signs to an assistive personnel (AP) on her team. Which of the following actions should the nurse plan to take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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