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. Close the documentation program on the computer:
This action is appropriate as it immediately stops unauthorized access to the client's medical information and prevents further viewing of protected health information (PHI).
b. Find out which staff member left the documentation program on the screen:
While it's important to identify any staff member who may have left the documentation program open, addressing this issue should not be the first priority. The immediate concern is stopping the unauthorized access to the client's information and ensuring that the visitor is aware of the confidentiality breach.
c. Tell the charge nurse that the visitor viewed a client’s protected health information:
Notifying the charge nurse about the incident is important, but it should not be the first action taken. The priority is to address the immediate breach of confidentiality and prevent further unauthorized access to the client's information.
d. Inform the visitor that client records are confidential:
This action may be appropriate after addressing the immediate breach of confidentiality. However, it should not be the first action taken as it does not immediately stop the unauthorized access to the client's information.
Correct Answer is D
Explanation
a. Instruct the client’s family to contact the insurance provider about the oxygen equipment:
This option involves instructing the client's family to take action by contacting the insurance provider. While it may be helpful for the family to be aware of insurance coverage, it does not directly address the immediate issue of the client needing oxygen upon discharge. Additionally, the family may not have the necessary information or authority to resolve the delivery delay.
b. Send an oxygen tank from the facility home with the client:
This option involves providing the client with an oxygen tank from the facility to ensure they have access to oxygen upon discharge. While it may temporarily address the client's immediate need, it may not be feasible or appropriate for the facility to provide oxygen equipment directly without coordinating with the equipment company and following proper protocols.
c. Contact social services about the delivery of the oxygen equipment:
This option involves contacting social services to seek assistance with resolving the delay in oxygen equipment delivery. Social services may be able to intervene and expedite the delivery process or explore alternative solutions to ensure the client's needs are met. Involving social services can be beneficial in navigating complex discharge issues.
d. Notify the provider about the delayed oxygen tank delivery:
It is important to inform the provider about the delay in oxygen equipment delivery so they can be aware of the situation and make any necessary adjustments to the discharge plan or arrange for alternative solutions. The provider may also assist in expediting the delivery or provide additional instructions for managing the situation.
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