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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Rationale:
A. "It is time to sign the consent so your treatment can begin." dismisses the client's valid question about alternative options and does not address their concern.
B. "Have you discussed other treatments with your provider?" is an appropriate response as it encourages the client to seek information about alternatives from their healthcare provider, who can offer comprehensive options and explanations.
C. "I can inform the surgeon you do not want the surgery." does not address the client's question about alternatives and assumes the client’s decision without further discussion.
D. "I would not have this type of surgery if I were you." is a personal opinion and is not appropriate for a nurse to provide, as it is not based on the client’s individual medical needs or informed consent principles.
Correct Answer is D
Explanation
Rationale:
A. A client who reports pain as 4 on a scale of 1 to 10 at 0800 now reports pain as 6 needs pain management, but this is less urgent compared to potential signs of hypotension.
B. A client whose wound drainage at 0800 was sanguineous and now it is serosanguineous indicates normal progression of wound healing; thus, it is less critical.
C. A client who has a prescription for insulin and his premeal capillary blood glucose was 110 mg/dL and his post-meal capillary blood glucose is now 160 mg/dL needs blood glucose management, but this is less urgent than assessing for potential hypovolemia or shock.
D. A client whose blood pressure at 0800 was 138/86 mm Hg and at 1200 is 106/60 mm Hg is experiencing a significant drop in blood pressure, which could indicate hypovolemia or shock. This requires immediate assessment and intervention to prevent complications.
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