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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"B"}
Explanation
False Imprisonment: This refers to the unlawful restraint of an individual's freedom of movement. By applying wrist restraints without a clear and immediate order from a provider or without proper justification, the nurse could be restricting the client's freedom of movement inappropriately.
Applying wrist restraints to the client: This action is a key factor in the potential for false imprisonment. Restraints should be used only when necessary and with proper authorization and documentation, particularly in non-emergency situations.
Correct Answer is C
Explanation
A. "The client works in the hospital radiology department": This information is irrelevant to the client’s current health status and does not imply a need for total care by the nurse.
B. "The client discussed having prior thoughts of suicide": While suicidal ideation is serious and requires careful monitoring and assessment, this information alone does not necessarily indicate that the nurse must assume total care. A nurse would still delegate non-critical tasks to the AP, but constant monitoring and appropriate interventions would still be the nurse’s responsibility.
C. "The client's blood pressure and pulse have been fluctuating throughout the day": Fluctuating vital signs, especially blood pressure and pulse, can indicate an unstable condition that may require immediate attention and careful monitoring. This scenario suggests that the client’s condition may be critical and requires ongoing assessment and evaluation by the nurse, rather than simply delegating tasks like monitoring vital signs to assistive personnel (AP). The nurse needs to assess the situation thoroughly, interpret the fluctuations, and adjust the care plan accordingly.
D. "The client's family members have been present most of the day": Family presence alone does not impact the need for total care by the nurse. It is important for the nurse to communicate with the family, but this statement does not indicate the need for the nurse to assume total care over other team members.
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