The nurse is caring for a group of clients with the help of a practical nurse (PN). Which nursing action(s) should the nurse assign to the PN? (Select all that apply)
Obtain postoperative vital signs for a client one day following unilateral knee arthroplasty.
Perform daily surgical dressing change for a client who had an abdominal hysterectomy.
Initiate patient controlled analgesia (PCA. pumps for two clients immediately postoperatively.
Start the second blood transfusion for a client twelve hours following a below knee amputation.
Monitor a dose of warfarin per protocol for a client with type 2 diabetes mellitus (DM).
Correct Answer : A,B,E
Choice C reason: Initiating patient controlled analgesia (PCA. pumps for two clients immediately postoperatively is not a nursing action that can be assigned to the PN. PCA pump is a device that allows the client to self-administer pain medication through an IV line by pressing a button. PCA pump should be initiated by the nurse after verifying the prescription, setting the parameters, educating the client, and ensuring safety and effectiveness. The PN does not have the authority or competency to initiate PCA pump or adjust its settings.
Choice D reason: Starting the second blood transfusion for a client twelve hours following a below knee amputation is not a nursing action that can be assigned to the PN. Blood transfusion is a procedure that delivers donated blood or blood products into the client's bloodstream through an IV line. Blood transfusion should be started by the nurse after verifying the prescription, checking the blood type and compatibility, obtaining informed consent, and monitoring for any adverse reactions. The PN does not have the authority or competency to start blood transfusion or manage its complications.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A: Mark an outline of the 'olive-shaped' mass in the right epigastric area. This is not a priority action, as it does not address the immediate needs of the infant. The 'olive-shaped' mass is a sign of pyloric stenosis, but it does not affect the infant's hydration or nutrition.
Choice B: Instruct parents regarding care of the incisional area. This is an important action, but not a priority before surgery. The parents need to know how to care for the incisional area after surgery, but this can be done later.
Choice C: Monitor amount of intake and infant's response to feedings. This is a relevant action, but not a priority before surgery. The infant with pyloric stenosis may have vomiting, dehydration, and electrolyte imbalance due to gastric outlet obstruction. Monitoring intake and output can help assess the severity of these problems, but it does not correct them.
Choice D: Initiate a continuous infusion of IV fluids per prescription. This is the priority action before surgery, as it can prevent or treat dehydration and electrolyte imbalance in the infant. IV fluids can also help maintain blood volume and perfusion during surgery.
Correct Answer is C
Explanation
Choice A: Measuring urine output daily is not a specific statement for the nurse to include, as this is a general recommendation for all clients with urinary catheters and does not address the potential complications of a suprapubic catheter. This is a distractor choice.
Choice B: Observing urine color and clarity is not a relevant statement for the nurse to include, as this does not reflect the condition of the suprapubic catheter or its insertion site. This is another distractor choice.
Choice C: Inspecting genital area for signs of infection is an important statement for the nurse to include, as this can help detect and prevent urinary tract infection, peritonitis, or abscess formation, which are common risks associated with suprapubic catheters. Therefore, this is the correct choice.
Choice D: Palpating flank area for tenderness is not a necessary statement for the nurse to include, as this is not an accurate or reliable method to assess for kidney function or damage, which are unlikely to occur with a suprapubic catheter. This is another distractor choice.
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