A nurse is delegating tasks for an assistive personnel (AP) to perform for a client who is 1-day postoperative following cardiac surgery. Which of the following tasks should the nurse perform herself?

Helping the client into the shower

Ambulating the client in the hallway

Measuring vital signs

Removing the sternal dressing

Answer and Explanation

The Correct Answer is D

A. Helping the client into the shower: This task can be safely delegated to an assistive personnel (AP). The AP can help the client with activities of daily living such as showering, as long as the client is stable and does not require close monitoring.

B. Ambulating the client in the hallway: This task can also be delegated to an AP. Assisting with ambulation is within the scope of practice for an AP, provided the client is stable and there are no specific concerns that require a nurse’s assessment.

C. Measuring vital signs: While measuring vital signs is a critical task, it can be delegated to an AP. The AP can be trained to accurately measure and report vital signs. However, the nurse should review and interpret the results.

D. Removing the sternal dressing: This is the correct answer. Removing a sternal dressing after cardiac surgery is a complex task that requires a nurse’s expertise2. The nurse needs to assess the surgical site for signs of infection or complications, which is beyond the scope of practice for an AP. Therefore, this task should not be delegated and should be performed by the nurse herself

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Correct Answer is C

Explanation

A) "The client has developed drooping facial features":
This statement provides essential information regarding a new symptom that the client has developed, which is drooping facial features. This is crucial information for the provider to understand the current status of the client's condition. However, it's more pertinent to the assessment and current issue rather than the client's background.

B) "The client may benefit from a neurology consult":
While a neurology consult may indeed be necessary based on the client's symptoms, it falls more under the assessment and recommendation components of the SBAR communication tool. The background component should focus on providing the provider with pertinent information about the client's current condition and relevant history.

C) "The client has a history of hypertension":
This statement is the correct choice. It provides important background information about the client's medical history, which is relevant to the current situation. The history of hypertension could potentially contribute to the development of drooping facial features, as certain complications of hypertension can lead to neurological symptoms.

D) “The client is disoriented and pupils are slow to respond to light":
While disorientation and pupil response are significant clinical findings, they are not mentioned in the stem of the question. The background component of the SBAR should focus on the specific information related to the current issue, which in this case is the development of drooping facial features.

A. S3 heart sounds B. Irregular pulsations C. Bradycardia D. Increase in point of maximum impulse (PMI)

Correct Answer is B

Explanation

A) S3 heart sounds:
S3 heart sounds are typically associated with heart failure and are not directly related to premature ventricular contractions (PVCs). S3 heart sounds occur during the early diastolic phase and are heard immediately after S2.

B) Irregular pulsations:
This is the correct choice. Premature ventricular contractions (PVCs) can cause irregular pulsations in the pulse. PVCs are premature contractions originating from the ventricles, which can interrupt the normal rhythm of the heart and lead to irregularities in the pulse.

C) Bradycardia:
Premature ventricular contractions (PVCs) can lead to various rhythm disturbances, but bradycardia (slow heart rate) is not typically associated with PVCs. In fact, PVCs often occur in the context of tachycardia (rapid heart rate).

D) Increase in point of maximum impulse (PMI):
An increase in the point of maximum impulse (PMI) is not typically associated with premature ventricular contractions (PVCs). The PMI refers to the location where the apex of the heart is palpated during systole and is not directly affected by PVCs.

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A nurse is delegating tasks for an assistive personnel (AP) to perform for a client who is 1-day postoperative following cardiac surgery. Which of the following tasks should the nurse perform herself?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has hypertension and recently developed drooping facial features. When contacting the provider, which of the following statements should the nurse include as part of the background component of the SBAR communication tool?

Correct Answer is C

Explanation

A nurse is collecting data from a client who is receiving continuous cardiac monitoring that is indicating premature ventricular contractions (PVCs). Which of the following findings should the nurse expect when assessing the client?

Correct Answer is B

Explanation

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