A nurse is preparing to delegate tasks to an assistive personnel after receiving change-of-shift report. The nurse should assign the AP to obtain vital signs from which of the following clients?
A client who has just returned from the PACU
A client who has a blood pressure of 110/68 mm Hg
A client who is experiencing chest pain
A client who has a fasting blood glucose of 104 mg/dL
The Correct Answer is B
a. A client who has just returned from the PACU:
Vital signs for a client who has just returned from the Post-Anesthesia Care Unit (PACU) are usually obtained by licensed nursing staff due to the potential for complications and the need for close monitoring.
b. A client who has a blood pressure of 110/68 mm Hg:
This client has stable vital signs, and obtaining blood pressure measurements within normal range is a routine task suitable for delegation to assistive personnel.
c. A client who is experiencing chest pain:
Clients experiencing chest pain require immediate assessment by licensed nursing staff or a healthcare provider. This is not a task appropriate for delegation to assistive personnel.
d. A client who has a fasting blood glucose of 104 mg/dL:
Monitoring blood glucose levels is typically within the scope of licensed nursing staff. Delegating tasks related to clients with diabetes or glucose monitoring to assistive personnel may not be appropriate.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
a. "I should encrypt personal health information when sending emails."
This statement indicates an understanding of the importance of protecting confidential information during electronic communication. Encrypting personal health information in emails adds an extra layer of security to prevent unauthorized access.
b. "I can use another nurse’s password as long as I log off after using the computer."
This statement is incorrect and demonstrates a lack of understanding of client confidentiality. Sharing passwords is a violation of security policies and compromises the confidentiality of client information. Each nurse should have their unique login credentials to ensure accountability and traceability.
c. "I should discard personal health information documents in the trash before leaving the unit."
This statement is incorrect. Discarding personal health information in an unsecured manner, such as in the regular trash, can lead to unauthorized access and a breach of confidentiality. Proper disposal methods, such as shredding or using secure disposal containers, should be followed to protect sensitive information.
d. "I can post the client’s vital signs in the client’s room."
This statement is incorrect. Posting client information, including vital signs, in a public area like the client's room violates confidentiality. Personal health information should be shared only with authorized individuals involved in the patient's care and through secure communication methods. Posting such information in a public space compromises the client's privacy.
Correct Answer is B
Explanation
a. Rotavirus: Rotavirus is a common cause of diarrheal illness, especially in infants and young children. While it can cause significant morbidity and mortality, it typically does not require reporting to the state health department unless there is an unusual outbreak or cluster of cases.
b. Pertussis: Pertussis, also known as whooping cough, is a highly contagious bacterial respiratory infection caused by Bordetella pertussis. It can lead to severe coughing fits, especially in infants and young children, and can be life-threatening, particularly in vulnerable populations. Due to its potential for causing outbreaks and serious illness, cases of Pertussis are typically reportable to the state health department for surveillance and control measures.
c. Respiratory syncytial virus (RSV): RSV is a common respiratory virus that can cause mild to severe respiratory illness, particularly in young children, older adults, and individuals with weakened immune systems. While RSV infections can lead to hospitalizations, they are not typically reportable to the state health department unless there is a concern for a widespread outbreak or unusual pattern of cases.
d. Group B streptococcus (GBS) is a bacterium commonly found in the genital tract of adults, and while it can cause serious infections in newborns, it's not typically reportable to the state health department unless there are specific circumstances such as outbreaks or unusual patterns of infection.
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