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 reason: Quiet, calm surroundings are not a specific environmental factor for osteomalacia, which is a condition that causes softening and weakening of the bones due to vitamin D deficiency. However, they may be beneficial for promoting rest and comfort for the client.
Choice B reason: Stimulating sounds and activity are not a specific environmental factor for osteomalacia, which is a condition that causes softening and weakening of the bones due to vitamin D deficiency. However, they may be helpful for enhancing mood and cognition for the client.
Choice C reason: Cool, moist air is not a specific environmental factor for osteomalacia, which is a condition that causes softening and weakening of the bones due to vitamin D deficiency. However, it may be preferable for preventing dehydration and overheating for the client.
Correct Answer is ["A","C","D","E"]
Explanation
Choice A: Applying an allergy identification wrist band is an intervention that the nurse should implement, as this can alert other health care providers of the client's allergies and prevent adverse reactions. Therefore, this is a correct choice.
Choice B: Instructing the client to avoid medication containing milk and eggs is not an intervention that the nurse should implement, as this is not a common or relevant source of allergens for this client. This is an incorrect choice.
Choice C: Entering allergy information in the client's electronic medical record is an intervention that the nurse should implement, as this can ensure accurate and updated documentation of the client's allergies and facilitate communication among health care providers. Therefore, this is another correct choice.
Choice D: Ensuring the client's selections from her dietary menu is an intervention that the nurse should implement, as this can help avoid foods that may trigger allergic reactions or intolerance for this client. Therefore, this is another correct choice.
Choice E: Notifying the dietary department of the client's egg intolerance is an intervention that the nurse should implement, as this can help modify or substitute foods that contain eggs for this client. Therefore, this is another correct choice.
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