While the practical nurse (PN) and unlicensed assistive personnel (UAP) are turning a client with an abdominal incision, the client's incision eviscerates. Which task is best for the PN to assign to the UAP?
Keep the client calm.
Gather supplies.
Cover the wound.
Reposition the client.
The Correct Answer is B
A. While it’s important to keep the client calm, this task may not be the most critical or appropriate for a UAP in an emergency situation. The nurse typically leads in managing the client's immediate needs.
B. This is a crucial task because the PN will need sterile supplies (e.g., sterile saline, dressings) to manage the evisceration. The UAP can efficiently gather these supplies, allowing the PN to focus on assessing the client and providing immediate care. This delegation is appropriate because it helps expedite the response to a critical situation.
C. Covering the wound is a critical step in managing evisceration, which should be performed by the PN to ensure it is done correctly and to maintain sterile technique. The PN is responsible for the clinical management of the emergency.
D. Repositioning the client could exacerbate the situation or delay necessary interventions. The PN must assess and manage the evisceration while ensuring the client remains as stable as possible.
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Related Questions
Correct Answer is D
Explanation
A. Urinary output of 50 mL/hour is within normal limits and does not directly impact morning care instructions.
B. An oxygen saturation measurement of 95 to 96% is generally acceptable and does not necessitate specific morning care instructions.
C. A blood pressure of 144/84 mm Hg is elevated but not critical in the context of morning care instructions for the UAP.
D. Orientation to person only indicates a cognitive impairment that could affect the client’s ability to understand or follow instructions, cooperate during care, and ensure safety during activities like bathing or moving. This is the most critical factor to consider when providing instructions to the UAP.
Correct Answer is C
Explanation
A. Feeling for a carotid pulse is part of the assessment process but is not the first step in responding to an unresponsive client. Immediate action to summon emergency help is the priority.
B. Bringing a glucometer to the room is not appropriate at this stage. While checking blood glucose might be necessary, the first step is to get emergency assistance.
C. Obtaining emergency help is the most critical first step when encountering an unresponsive client. Emergency help ensures that appropriate interventions are initiated promptly.
D. Checking the blood pressure is part of a complete assessment but is not the most urgent action. The priority is to call for emergency assistance rather than performing further assessments.
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