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. A client with Alzheimer's disease and bacterial pneumonia with newly onset restlessness may be experiencing delirium, which could indicate a worsening of their pneumonia or another underlying issue. Delirium can be a sign of a serious medical condition and requires immediate assessment to determine the cause and provide appropriate intervention.
b. While a fasting blood glucose level of 200mg/dL in a newly admitted client with diabetes mellitus is high and requires attention, it is not as urgent as assessing a client with newly onset restlessness, as described in option a.
c. A client who is 24 hours postoperative following surgical reduction of a hip fracture and reports a pain level of 7 on a scale from 0-10 requires assessment and pain management, but it is not as urgent as assessing the client with newly onset restlessness.
d. A client who is 3 days postoperative following abdominal surgery and is ready for discharge may require routine assessment and preparation for discharge, but it is not as urgent as assessing the client with newly onset restlessness.
Correct Answer is ["C"]
Explanation
a. Store opened bottles of normal saline in a refrigerator for up to 48 hours:
Incorrect. Once opened, bottles of normal saline should generally be used within a short time frame (typically 24 hours) and should not be stored for extended periods to prevent contamination. This practice could lead to infection risks and is not recommended as a cost-containment measure.
b. Wait to dispose of sharps containers until they are completely full:
Incorrect. Overfilling sharps containers increases the risk of needle-stick injuries and potential exposure to bloodborne pathogens. Sharps containers should be disposed of when they are about three-quarters full to maintain safety.
c. Use clean gloves rather than sterile gloves for colostomy care:
Correct. For colostomy care, clean gloves are generally sufficient as it is a clean procedure, not a sterile one. Using clean gloves instead of sterile gloves reduces costs without compromising patient safety.
d. Return unused supplies from the bedside to the unit’s supply stock:
Incorrect. Returning unused supplies to the general supply stock can pose a risk of cross-contamination and infection. Once supplies have been brought to a patient's bedside, they are considered contaminated and should not be returned to the supply area.
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