A nurse is caring for four clients who are postoperative from surgery 24 hr ago. At 1200 the nurse assesses the clients. Which of the following clients is the nurse's priority?
A client who reports pain as 4 on a scale of 1 to 10 at 0800 now reports pain as 6
A client whose wound drainage at 0800 was sanguineous and now it is serosanguineous
A client who has a prescription for insulin and his premeal capillary blood glucose was 110 mg/dL and his post-meal capillary blood glucose is now 160 mg/dL
A client whose blood pressure at 0800 was 138/86 mm Hg and at 1200 is 106/60 mm Hg
The Correct Answer is D
Rationale:
A. A client who reports pain as 4 on a scale of 1 to 10 at 0800 now reports pain as 6 needs pain management, but this is less urgent compared to potential signs of hypotension.
B. A client whose wound drainage at 0800 was sanguineous and now it is serosanguineous indicates normal progression of wound healing; thus, it is less critical.
C. A client who has a prescription for insulin and his premeal capillary blood glucose was 110 mg/dL and his post-meal capillary blood glucose is now 160 mg/dL needs blood glucose management, but this is less urgent than assessing for potential hypovolemia or shock.
D. A client whose blood pressure at 0800 was 138/86 mm Hg and at 1200 is 106/60 mm Hg is experiencing a significant drop in blood pressure, which could indicate hypovolemia or shock. This requires immediate assessment and intervention to prevent complications.
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Correct Answer is A
Explanation
Rationale:
A. Ask the AP about her concerns with the assignment is appropriate as it allows the nurse to understand and address any potential issues or reasons for refusal.
B. Report the AP to the charge nurse should only be done if the refusal cannot be resolved through discussion.
C. Take the specimen to the laboratory should be done if needed, but it is important to first understand why the AP refused.
D. Complete an incident report might be premature without understanding the reason behind the refusal.
Correct Answer is C
Explanation
Rationale:
A. Determining social skills is not directly related to task delegation.
B. Assessing ability to follow the client's teaching plan is beyond the scope of AP duties.
C. Providing a clear description of the task ensures that the AP understands what is expected, which is essential for effective delegation.
D. Evaluating ability to work with peers is important but not the primary focus for task delegation.