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 D
Explanation
a. Review the chart for nonrestraint alternatives for agitation:
This action involves assessing the client's history, current condition, and any documented alternatives to restraints for managing agitation. While exploring nonrestraint interventions is important, addressing the immediate issue of inappropriate restraint use should take precedence.
b. Inform the unit manager:
Notifying the unit manager about the incident is important for escalating the situation and involving higher-level management in addressing the inappropriate use of restraints. However, before escalating, the immediate needs of the client should be addressed.
c. Speak with the AP about the incident:
Engaging in a conversation with the assistive personnel (AP) who applied the restraints allows for clarification of the situation, identification of any misunderstandings or training needs regarding restraint use, and immediate removal of the restraints if necessary. However, ensuring the client's safety should be the first priority.
d. Remove the restraints from the client’s wrist:
In situations where restraints are applied without a prescription or appropriate authorization, it is crucial to remove the restraints promptly to prevent potential harm to the client. However, it is essential to address the root cause of the inappropriate use of restraints and ensure that the client receives appropriate care and monitoring following restraint removal.
Correct Answer is B
Explanation
a. A system for tracking client information:
Having a system for tracking client information is essential for effective disaster management, including during bioterrorism events. This system allows healthcare providers to monitor and manage the care of affected individuals, track exposure to biological agents, and coordinate response efforts. It facilitates communication and collaboration among healthcare teams and enables timely and accurate documentation of patient information, including symptoms, treatment, and outcomes.
b. A sufficient supply of personal protective equipment (PPE):
Personal protective equipment is critical in protecting healthcare workers and first responders from exposure to biological agents during a bioterrorism event. PPE includes items such as masks, gloves, gowns, and eye protection, which create a barrier between individuals and potentially hazardous substances. Having an adequate supply of PPE ensures that healthcare providers can safely care for affected individuals, minimize the risk of infection or contamination, and prevent the spread of disease within healthcare settings and the community.
c. A mental health specialist on the response team:
A mental health specialist plays a vital role in addressing the psychological and emotional needs of individuals affected by a bioterrorism event. Such events can cause fear, anxiety, trauma, and grief among survivors, healthcare workers, and the community. A mental health specialist provides support, counseling, and crisis intervention to help individuals cope with stress, trauma, and loss. They also assist in addressing psychosocial factors that may impact recovery and resilience, such as social support, coping mechanisms, and access to mental health services.
d. A network for communication between staff members and families:
Effective communication is essential for coordinating response efforts, disseminating information, and providing updates to staff members, patients, and their families during a bioterrorism event. A network for communication facilitates real-time communication and collaboration among healthcare teams, emergency responders, public health agencies, and community partners. It enables the sharing of critical information, such as situational updates, safety protocols, resource allocation, and instructions for affected individuals and their families. This communication network ensures that everyone receives timely and accurate information, reduces uncertainty and confusion, and enhances overall coordination and response effectiveness.
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