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 B
Explanation
Rationale:
A. Measuring I&O can be performed by an AP, as it does not require advanced skills or clinical judgment.
B. Reinforcing teaching about medication is within the LPN's scope of practice, as LPNs are trained to provide education and support based on the teaching provided by RNs or physicians.
C. Developing a plan of care is generally a responsibility of the RN, as it involves comprehensive assessment and planning.
D. Completing an admission assessment is a task for RNs due to its complexity and the need for a detailed clinical evaluation.
Correct Answer is B
Explanation
Rationale:
A. "The client works in the hospital radiology department." This information is important for understanding the client's background but does not indicate a need for total care by the nurse.
B. "The client discussed having prior thoughts of suicide." This statement indicates a high-risk situation requiring close monitoring and direct care by the nurse, rather than delegating tasks to an AP. The client's safety and mental health status necessitate the nurse's full attention.
C. "The client's blood pressure and pulse have been fluctuating throughout the day." While this information suggests the need for monitoring, it doesn't necessarily preclude the AP from assisting with certain tasks under the nurse's supervision.
D. "The client's family members have been present most of the day." This statement provides context but does not indicate a need for total care by the nurse.