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.
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Naxlex Comprehensive Predictor Exams
Related Questions
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.
Correct Answer is A
Explanation
a. “The client is in the radiology department for a chest x-ray.”
This information is relevant as it informs the oncoming nurse about the client's current location and the reason for the absence from the unit. It helps maintain awareness of the client's whereabouts and the ongoing diagnostic process.
b. “The client’s partner came to visit him 2 hrs. ago.”
While it's important to document visitor interactions in the client's chart, informing about a visit from 2 hours ago during a change-of-shift report may not be as pertinent to immediate patient care as other information. This detail can be communicated through other means, such as the client's chart or communication log.
c. “The client has routine vital signs prescribed.”is not as critical to include in the change-of-shift report because it is standard practice and does not provide specific, immediate information about the client’s current status or any changes that need to be monitored closely.
d. “The client is the president of a local bank.”
While interesting, this information is not relevant to the client's current medical condition or care plan. It does not contribute to the immediate care needs of the client and can be considered extraneous during a change-of-shift report.
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