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 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.
Correct Answer is B
Explanation
a. Advise him to complete less time-consuming tasks first:
This intervention may be helpful in prioritizing tasks and ensuring that essential care is provided in a timely manner. However, it does not address the underlying issue of difficulty focusing and may not address the root cause of the problem.
b. Recommend that he take time to plan at the beginning of his shift:
Planning at the beginning of the shift is essential for organizing tasks and prioritizing care. This intervention may help the newly licensed nurse improve their time management skills and focus by providing a structured approach to their work.
c. Offer to provide care for his clients while he takes a break:
While taking breaks is important for maintaining focus and preventing burnout, offering to provide care for his clients may not address the underlying issue of difficulty focusing and completing tasks. Additionally, taking over his tasks may not encourage the newly licensed nurse to develop the skills needed to improve his performance.
d. Ask other staff members to take over some of his tasks:
Asking other staff members to take over some of his tasks may provide temporary relief, but it does not address the underlying issue or help the newly licensed nurse develop the skills needed to improve his performance.
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