A nurse is caring for four postoperative clients. The nurse can delegate obtaining vital signs to an assistive personnel (AP) for which of the following clients?
A client who is 3 days postoperative following a craniotomy
A client who is 3 days postoperative following gastric bypass surgery
A client who is 2 hr postoperative following an abdominal hysterectomy
A client who is 1 hr postoperative following a thyroidectomy
The Correct Answer is B
Rationale:
A. A client who is 3 days postoperative following a craniotomy requires careful monitoring due to potential complications from brain surgery, so vital signs should be taken by a nurse.
B. A client who is 3 days postoperative following gastric bypass surgery is stable enough for an AP to obtain vital signs, as the risk of immediate postoperative complications is lower compared to more recent surgeries.
C. A client who is 2 hr postoperative following an abdominal hysterectomy requires close monitoring due to the recent surgery, so vital signs should be obtained by a nurse.
D. A client who is 1 hr postoperative following a thyroidectomy requires vigilant monitoring for potential complications from recent surgery, which should be done by a nurse.
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Related Questions
Correct Answer is D
Explanation
Rationale:
A. Assigning an RN to perform a central line dressing change is appropriate as it requires specialized skills and knowledge.
B. Assigning an AP to perform glucometer monitoring is within their scope of practice and is a suitable task.
C. Assigning two APs to ambulate clients is reasonable if the workload requires it.
D. Assigning a new graduate nurse to perform a wet-to-dry dressing change may be inappropriate if it requires more experience and skill than the new graduate has.
Correct Answer is C
Explanation
Rationale:
A. False imprisonment involves restricting a person’s freedom of movement, not administering medication against their will.
B. Assault involves the threat of harm, not the actual administration of medication.
C. Battery is the intentional touching of another person without consent, which includes administering medication to a competent person who has refused it.
D. Negligence involves failure to meet the standard of care, but administering medication against a patient’s wishes is more accurately described as battery.
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