A nurse on a mental health unit is caring for a client.

Nurses' Notes

Day 1, 1300:

Client admitted following a suicide attempt. Client's family reports client has not left bedroom in 1 week. Client previously. diagnosed with bipolar disorder.

Client reports feeling excessively tired and light-headed. Allergies: Client's family reports allergy to SSRIS (angioedema) and penicillin (anaphylaxis).

1600:

Client has been sleeping in their room since admission. Flat affect noted.

For each potential provider's prescription, click to specify if the potential prescription is anticipated or contraindicated for the client.

A. Correct. A 6-month-old infant who has croup and an O2 saturation of 92% on room air is at risk of respiratory distress and hypoxia. Croup causes inflammation and narrowing of the upper airway, which can compromise breathing. An O2 saturation of 92% is below the normal range of 95% to 100% and indicates inadequate oxygenation. This child needs immediate assessment and intervention to prevent further deterioration.

B. Incorrect. A 15-year-old adolescent who is 2 hr postoperative following an open reduction and internal fixation of the left ankle and is requesting pain medication has a priority need for pain management, but not as urgent as a child with respiratory compromise. The nurse should assess the adolescent's pain level, administer the prescribed analgesic, and monitor the effectiveness of the medication.

C. Incorrect. A 3-year-old toddler who has gastroenteritis, moderate dehydration, and had two loose bowel movements over the past 24 hr has a potential risk for fluid and electrolyte imbalance, but not as acute as a child with respiratory compromise. The nurse should monitor the toddler's intake and output, vital signs, weight, and skin turgor, and administer oral or intravenous fluids as prescribed.

D. Incorrect. A 10-year-old child who is awaiting surgery for an appendectomy and experienced sudden relief from pain may have a perforated appendix, which can lead to peritonitis and sepsis. However, this child is not as unstable as a child with respiratory compromise. The nurse should notify the surgeon of the change in pain status, monitor the child's vital signs, abdominal assessment, and laboratory results, and prepare the child for surgery.

A. Palpate the degree of edema. This is incorrect because palpating the degree of edema requires clinical judgment and skill, which are beyond the scope of practice of an AP.

B. Regulate IV pump fluid rate. This is incorrect because regulating IV pump fluid rate is a nursing responsibility that involves calculating and adjusting the infusion rate based on the client's condition and orders.

C. Measure the client's daily weight. This is correct because measuring the client's daily weight is a routine task that can be delegated to an AP, as long as the nurse provides clear instructions and monitors the results. The client's daily weight is an indicator of fluid balance and can help evaluate the effectiveness of treatment.

D. Assess the client's vital signs. This is incorrect because assessing the client's vital signs requires interpretation and analysis of data, which are nursing functions that cannot be delegated to an AP.