A nurse is caring for patients with electrolyte imbalances on a medical-surgical unit. Which common causes are correctly paired with the corresponding electrolyte imbalance?

Choice A reason:

Assessing the surgical dressing is crucial to monitor for signs of bleeding, infection, or other complications at the surgical site. The nurse should check the dressing for any excessive drainage, unusual color, or odor, which could indicate an infection or other issues. Ensuring the dressing is intact and clean helps in preventing wound contamination and promotes healing. This assessment is vital in the immediate postoperative period to detect any early signs of complications that may require prompt intervention.

Choice B reason:

Obtaining the vital signs is a fundamental assessment that provides critical information about the patient’s overall physiological status. Vital signs include blood pressure, heart rate, respiratory rate, and temperature. These measurements help in identifying any deviations from the normal ranges that could indicate complications such as hypovolemia, infection, or respiratory distress. Regular monitoring of vital signs allows the nurse to detect and respond to any changes in the patient’s condition promptly. Normal ranges for adults are typically: blood pressure 120/80 mmHg, heart rate 60-100 beats per minute, respiratory rate 12-20 breaths per minute, and temperature around 98.6°F (37°C).

Choice C reason:

Assessing the pain level is essential for effective pain management and patient comfort. Postoperative pain can significantly impact a patient’s recovery and ability to participate in necessary activities such as deep breathing and ambulation. The nurse should use a standardized pain assessment tool, such as the Numeric Rating Scale (0-10), to evaluate the patient’s pain intensity and quality. Effective pain management involves administering prescribed analgesics and evaluating their effectiveness, as well as implementing non-pharmacological interventions as needed. Proper pain control helps in reducing stress, promoting healing, and improving the overall recovery experience.

Choice D reason:

Assessing the respiratory rate and effort is critical to ensure that the patient is breathing adequately and not experiencing respiratory distress. Anesthesia and surgery can affect respiratory function, making it essential to monitor for signs of hypoxia, such as increased respiratory rate, use of accessory muscles, or cyanosis. The nurse should observe the patient’s breathing pattern, listen to breath sounds, and measure oxygen saturation levels using a pulse oximeter. Normal oxygen saturation levels are typically between 95-100%. Prompt identification and management of respiratory issues are crucial to prevent complications such as atelectasis and pneumonia.

Choice E reason:

Asking the patient if they have a ride home is not a priority assessment in the immediate postoperative period. While discharge planning is important, the primary focus should be on stabilizing the patient’s physiological status and addressing any immediate postoperative needs. Ensuring the patient has a ride home can be addressed later in the recovery process, once the patient is stable and ready for discharge. The initial assessments should prioritize monitoring for complications and ensuring the patient’s safety and comfort.

Choice A reason:

Instructing the client to hold a pillow to the abdominal incision when coughing is a task that involves patient education and reinforcement of postoperative care techniques. While LPNs/LVNs can provide basic patient education, this specific task requires ensuring that the patient understands the importance of splinting the incision to reduce pain and prevent complications such as wound dehiscence. This level of instruction is typically within the scope of practice for a registered nurse (RN), who has more extensive training in patient education and postoperative care. Therefore, this task is not the most appropriate for delegation to an LPN/LVN.

Choice B reason:

Obtaining bedside blood glucose is a task that is appropriate for delegation to an LPN/LVN. LPNs/LVNs are trained to perform routine tasks such as monitoring vital signs, including blood glucose levels, especially in patients with diabetes. This task involves using a glucometer to measure the patient’s blood sugar levels and recording the results. It does not require complex clinical judgment, making it suitable for an LPN/LVN. Regular monitoring of blood glucose is crucial for managing diabetes and preventing complications such as hyperglycemia or hypoglycemia.

Choice C reason:

Creating the plan of care is a complex task that involves comprehensive assessment, critical thinking, and clinical judgment. This task is typically within the scope of practice for an RN, who is trained to develop and implement individualized care plans based on a thorough assessment of the patient’s needs, medical history, and current condition. The RN collaborates with other healthcare team members to ensure that the care plan addresses all aspects of the patient’s recovery and health maintenance. LPNs/LVNs can contribute to the care plan by providing input and performing delegated tasks, but they do not have the authority to create the plan of care independently.

Choice D reason:

Documenting postoperative teaching involves recording the education provided to the patient about their postoperative care, including instructions on medication, activity restrictions, wound care, and signs of complications to watch for. This task requires ensuring that the patient understands the information and can follow the instructions correctly. While LPNs/LVNs can reinforce teaching and provide basic education, the initial comprehensive teaching and documentation are typically the responsibility of an RN. The RN ensures that the teaching is thorough and that the patient has the necessary knowledge to manage their care at home.