Which actions included in the discharge teaching plan can the nurse delegate to assistive personnel (AP)?

Show the caregiver how to check the patient’s temperature and blood pressure.

Give the patient a pamphlet that reinforces teaching done by the nurse.

Evaluate whether the patient and caregiver understand the teaching.

Plan topics for the discharge teaching session with the patient and caregiver.

Answer and Explanation

The Correct Answer is A

Choice A: Show the caregiver how to check the patient’s temperature and blood pressure
Showing the caregiver how to check the patient’s temperature and blood pressure involves direct patient education and demonstration, which requires the clinical judgment and expertise of a licensed nurse. This task ensures that the caregiver understands the correct techniques and can accurately monitor the patient’s vital signs. Delegating this task to assistive personnel (AP) is not appropriate because it requires a higher level of skill and knowledge to teach and verify understanding.
Choice B: Give the patient a pamphlet that reinforces teaching done by the nurse
Giving the patient a pamphlet that reinforces teaching done by the nurse is a task that can be delegated to assistive personnel (AP). This action does not require clinical judgment or advanced skills. The pamphlet serves as a supplementary resource to the verbal and hands-on education provided by the nurse. It is a straightforward task that AP can perform, ensuring that the patient has access to written information that reinforces the nurse’s teaching.
Choice C: Evaluate whether the patient and caregiver understand the teaching
Evaluating whether the patient and caregiver understand the teaching is a critical component of the discharge process that requires the clinical judgment of a licensed nurse. This task involves assessing the patient’s and caregiver’s comprehension, identifying any gaps in understanding, and providing additional education as needed. It is not appropriate to delegate this responsibility to assistive personnel (AP) because it requires professional assessment skills.
Choice D: Plan topics for the discharge teaching session with the patient and caregiver
Planning topics for the discharge teaching session with the patient and caregiver involves developing a comprehensive and individualized teaching plan based on the patient’s specific needs and condition. This task requires the expertise and clinical judgment of a licensed nurse to ensure that all relevant topics are covered and that the teaching plan is tailored to the patient’s situation. Delegating this task to assistive personnel (AP) is not appropriate because it requires advanced planning and professional knowledge.

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Correct Answer is A

Explanation

Choice A: True

Urinary tract infections (UTIs) are indeed the most common type of healthcare-associated infection (HAI). According to the Centers for Disease Control and Prevention (CDC), UTIs account for more than 30% of infections reported by acute care hospitals. These infections are primarily caused by the use of catheters and other instrumentation of the urinary tract, which can introduce bacteria and lead to infection. The high prevalence of UTIs in healthcare settings underscores the importance of stringent infection control practices to prevent these infections.

Choice B: False

The statement that UTIs are not the most common healthcare-associated infection is incorrect. While other types of HAIs, such as surgical site infections, bloodstream infections, and pneumonia, are also significant, UTIs remain the most frequently reported. The use of urinary catheters is a major risk factor, and efforts to reduce catheter use and improve catheter care are critical in preventing these infections.

A. Potassium (K+) level of 5.6 mEq/L. B. BP 109/70. C. No nausea and vomiting. D. Watery diarrhea for 3 days. E. Lightheaded when standing up. F. Blood Urea Nitrogen (BUN) level of 30 mg/dL. G. HR 102. H. Lung sounds are clear.

Correct Answer is ["A","D","E","F","G"]

Explanation

Choice A reason:

Potassium (K+) level of 5.6 mEq/L is a critical finding that requires immediate follow-up. Hyperkalemia, defined as a potassium level greater than 5.0 mEq/L, can lead to severe cardiac complications, including arrhythmias and cardiac arrest. The patient’s ECG changes, such as alterations in the T wave and PR interval, indicate that the elevated potassium level is already affecting cardiac function. Immediate intervention is necessary to lower the potassium level and prevent life-threatening complications. Normal potassium levels range from 3.5 to 5.0 mEq/L.

Choice B reason:

BP 109/70 is slightly lower than the normal range but not critically low. While it is important to monitor blood pressure, this finding does not require immediate follow-up compared to the other more critical issues. The patient’s blood pressure should be monitored regularly to ensure it does not drop further, but it is not the most urgent concern at this moment. Normal blood pressure is typically around 120/80 mmHg.

Choice C reason:

No nausea and vomiting is a positive finding indicating that the patient is not losing additional fluids and electrolytes through emesis. While it is important to note, it does not require follow-up as it does not pose an immediate risk to the patient’s health. The absence of nausea and vomiting is beneficial but does not address the primary concerns related to fluid and electrolyte imbalances.

Choice D reason:

Watery diarrhea for 3 days is a significant finding that requires follow-up due to the risk of dehydration and electrolyte imbalances. Diarrhea leads to the loss of fluids and essential electrolytes, which can result in complications such as hypovolemia and electrolyte disturbances. The patient’s ongoing diarrhea needs to be managed to prevent further fluid loss and stabilize their condition. This symptom is directly contributing to the patient’s current state of weakness and electrolyte imbalance.

Choice E reason:

Lightheaded when standing up suggests orthostatic hypotension, which can be a result of dehydration or electrolyte imbalances. This symptom indicates that the patient is experiencing hemodynamic instability, likely due to fluid loss from diarrhea. It is important to address this issue to prevent falls and further complications. Managing the underlying cause, such as rehydration and correcting electrolyte imbalances, will help stabilize the patient’s condition.

Choice F reason:

Blood Urea Nitrogen (BUN) level of 30 mg/dL is elevated, indicating impaired kidney function or dehydration. Normal BUN levels range from 6 to 24 mg/dL. An elevated BUN level suggests that the kidneys are struggling to manage the body’s waste products and fluid balance. This finding is critical for understanding the extent of the patient’s fluid and electrolyte imbalances and guiding appropriate interventions. Addressing the elevated BUN is essential for improving renal function and overall patient health.

Choice G reason:

HR 102 is slightly elevated, indicating tachycardia. Normal heart rate ranges from 60 to 100 beats per minute. Tachycardia can be a sign of dehydration, pain, anxiety, or other underlying conditions. In this case, the elevated heart rate is likely related to the patient’s dehydration and electrolyte imbalances. Monitoring and managing the heart rate is important to ensure the patient’s cardiovascular stability. Interventions to correct fluid and electrolyte imbalances will help normalize the heart rate.

Choice H reason:

Lung sounds are clear is an important assessment finding but does not require follow-up in the context of fluid and electrolyte imbalances. Clear lung sounds indicate that the patient is not experiencing respiratory complications such as pulmonary edema or infection. While this is a positive finding, it does not address the immediate concerns related to the patient’s fluid and electrolyte status.

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Which actions included in the discharge teaching plan can the nurse delegate to assistive personnel (AP)?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Urinary tract infections are the most common healthcare-associated infection.

Correct Answer is A

Explanation

Instructions: Use this scenario for the next 4 questions. Exhibits Indicate 5 findings in the assessment and laboratory results which require follow-up by the nurse.

Correct Answer is ["A","D","E","F","G"]

Explanation

A priority goal of the nursing pain assessment is to:

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The OR nurse gives an SBAR to the PACU nurse. This verbal report should include which four statements?

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Neutropenia increases the patient’s risk for life-threatening infection and sepsis.