A nurse is assigned a group of clients at the start of the shift. Which of the following clients should the nurse plan to care for first?
A client requesting a referral for home health services
A client asking about his PCA pump that contains morphine
A client who needs assistance with a bath
A client who has questions about his new prescription
The Correct Answer is B
Rationale:
A. Requesting a referral is important but not immediately critical compared to other needs.
B. Asking about a PCA pump with morphine indicates a potential issue with pain management or medication delivery that needs immediate attention.
C. Assisting with a bath is important for comfort and hygiene but is less urgent compared to immediate pain management.
D. Questions about a new prescription should be addressed but are generally less urgent than issues related to pain management.
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Correct Answer is B
Explanation
Rationale:
A. Call the provider for a stat DNR order is not appropriate as the client is already in a critical state requiring immediate action.
B. Call the emergency response team is necessary as the client is pulseless, and resuscitation should be initiated according to standard procedures until a DNR order is confirmed.
C. Seek immediate help from the risk manager is not appropriate at this moment; the immediate concern is the client's emergency situation.
D. Respect the family's wishes and do nothing is not appropriate as immediate life-saving measures should be taken until a formal DNR order is in place.
Correct Answer is C
Explanation
Rationale:
A. Verify the AP's educational preparation prior to delegating the task is unnecessary if the AP has been trained and is competent in the task.
B. Observe the AP as she obtains the vital signs of each client is not required for routine tasks unless there is a concern about performance.
C. Determine the time frame the AP should report the results is crucial for ensuring timely and accurate reporting, which is necessary for effective patient care.
D. Ask the AP to take the vital signs of the client returning from surgery first might not be appropriate without considering the urgency of all clients’ conditions.