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
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
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Answer: C. Orange ice pop
Rationale:
A) Ice cream: Although cold, ice cream can be thick and may stick to the throat, potentially causing discomfort and an urge to clear the throat, which could disrupt the healing tissue and increase bleeding risk.
B) Hot tea: Hot beverages can irritate the surgical site and increase the risk of bleeding due to the heat dilating blood vessels in the area. Cold or room temperature items are recommended post-tonsillectomy.
C) Orange ice pop: An orange ice pop is cold and soothing, which can reduce swelling and pain. Its smooth texture is easy on the throat and unlikely to cause irritation, making it an ideal snack post-tonsillectomy.
D) Cranberry juice: Cranberry juice is acidic and can irritate the throat, causing discomfort and possibly increasing inflammation at the surgical site. Non-acidic, cold foods are preferable to aid in comfort and healing.
Correct Answer is C
Explanation
(a) Administer another dose of the beta-blocker as prescribed by the physician: Administering another dose of the beta-blocker may not be the best course of action. If the client is experiencing fatigue and weakness, it could be a sign that the medication’s side effects are causing these symptoms. Administering an additional dose may exacerbate these side effects. Adjusting the medication regimen should be done under the direction of the healthcare provider.
(b) Offer the client a salty snack to improve blood pressure: Offering a salty snack may increase blood pressure, but it does not address the underlying issue of the medication’s side effects. Moreover, a diet high in salt can lead to other health problems, such as heart disease and stroke.
(c) Document the client’s symptoms and notify the healthcare provider: Documenting the client’s symptoms and notifying the healthcare provider is the most appropriate initial nursing action. The healthcare provider needs to be informed so that appropriate changes to the medication regimen can be made.
(d) Encourage the client to participate in physical therapy exercises: While physical therapy exercises can be beneficial for overall health, they do not address the immediate concern of the medication’s side effects. The client’s symptoms are indicative of medication side effects rather than a lack of physical activity. While physical therapy is important, it is not the most immediate priority in addressing the client’s current symptoms.
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