Which of the following instructions provided by a nurse reflects effective communication regarding delegation of a task to an assistive personnel (AP)?
"Take vital signs every 2 hours for the client who had a cholecystectomy in room 6122.”
"Check the urinary output at 11:00 for John Doe and report it to me immediately.”
"Report to me if the chest tube drainage is excessive for Jane Doe in room 2438.”
"Please notify me of any clients whose vital signs or blood glucose levels are significant.”
The Correct Answer is B
The answer is b. "Check the urinary output at 11:00 for John Doe and report it to me immediately.”
a. "Take vital signs every 2 hours for the client who had a cholecystectomy in room 6122.” is wrong because it does not specify which client to monitor. The AP should know the client’s name and room number for identification and safety purposes.
c. "Report to me if the chest tube drainage is excessive for Jane Doe in room 2438.” is wrong because it does not define what constitutes excessive drainage. The nurse should provide clear and measurable criteria for the AP to follow.
d. "Please notify me of any clients whose vital signs or blood glucose levels are significant.” is wrong because it is vague and does not indicate which clients to check, how often to check them, or what values are significant. The nurse should provide specific and individualized instructions for each client
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The correct answer is choice B: "This is a procedure that does not require written informed consent."
Choice B rationale: Informed consent is typically required for invasive procedures, surgery, or treatments that carry significant risks. While inserting an indwelling urinary catheter is considered an invasive procedure, it is generally not a procedure that requires written informed consent. Nurses often have standing orders or standardized procedures in place for catheterization, and consent is usually implied or obtained verbally.
Choice A rationale: Although providers prescribe procedures, consent is still necessary in many cases. However, as mentioned above, written informed consent is not typically required for urinary catheter insertion due to its routine nature in medical care.
Choice C rationale: Discussing the issue with the charge nurse is unnecessary since written informed consent is not generally required for this procedure. The nurse should instead focus on educating the family about standard hospital practices.
Choice D rationale: Asking the family to sign the informed consent form at this point is not appropriate, as it implies that the procedure should not have been performed without written consent. Additionally, urinary catheterization does not typically require written informed consent, so asking them to sign a form could create confusion or unnecessary concern.
Correct Answer is C
Explanation
The correct answer is C.
Choice A: Take extra wheelchairs to the emergency department While having extra wheelchairs available can be helpful in a disaster situation, it is not the primary responsibility of the PACU charge nurse. The logistics of equipment distribution would typically be managed by a different team or department.
Choice B: Send PACU assistive personnel to assist with triage Triage is a critical part of disaster response, but it is typically performed by trained emergency department personnel or those with specific training in disaster triage. PACU personnel should focus on their area of expertise, which is post-anesthesia care.
Choice C: Identify stable clients for transfer to a surgical unit This is the correct action. By identifying stable clients for transfer, the PACU charge nurse can free up space for incoming patients who may require immediate post-operative care. This action helps to ensure that the PACU is ready to receive patients who are likely to come from the emergency department after immediate lifesaving interventions.
Choice D: Report to the command center for further instructions While communication with the command center is important in a disaster situation, the PACU charge nurse’s primary responsibility is to manage the care environment and patient flow within their specific unit. Other teams or personnel would likely handle tasks like reporting to the command center.
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