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A nurse is caring for four postoperative clients. The nurse can delegate obtaining vital signs to an assistive personnel (AP) for which of the following clients?

A.

A client who is 3 days postoperative following a craniotomy

B.

A client who is 3 days postoperative following gastric bypass surgery

C.

A client who is 2 hr postoperative following an abdominal hysterectomy

D.

A client who is 1 hr postoperative following a thyroidectomy

Answer and Explanation

The Correct Answer is B

Rationale:

 

A. A client who is 3 days postoperative following a craniotomy requires careful monitoring due to potential complications from brain surgery, so vital signs should be taken by a nurse.

 

B. A client who is 3 days postoperative following gastric bypass surgery is stable enough for an AP to obtain vital signs, as the risk of immediate postoperative complications is lower compared to more recent surgeries.

 

C. A client who is 2 hr postoperative following an abdominal hysterectomy requires close monitoring due to the recent surgery, so vital signs should be obtained by a nurse.

 

D. A client who is 1 hr postoperative following a thyroidectomy requires vigilant monitoring for potential complications from recent surgery, which should be done by a nurse.


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View Related questions

Correct Answer is ["B","E","F","I"]

Explanation

Rationale:

A. Typically involved in helping clients with activities of daily living due to physical or cognitive impairments, which is not the primary focus in this scenario.

B. May be involved if there is a need for possible surgical management due to complications or disease progression. Surgical intervention can be necessary for Crohn's disease, particularly if there are abscesses, strictures, or fistulas.

C. While important in general rehabilitation, physical therapy is not specifically indicated in this case unless there are complications affecting physical mobility.

D. While they perform diagnostic imaging, they are not directly involved in the ongoing care plan or treatment decisions.

E. Essential for managing nutritional needs, especially given the client's weight loss and inability to keep food down. A dietitian can help develop a plan to address nutritional deficiencies and manage symptoms through diet.

F. A specialist in gastrointestinal diseases who will likely be a key member of the team for managing and evaluating the client's Crohn's disease, overseeing medical and therapeutic interventions.

G. Generally involved if there are issues with swallowing or speech, which is not indicated here.

H. Though crucial in medication management, their role is more supportive in reviewing medication plans rather than direct patient care involvement in this specific scenario.

I. Important for addressing psychosocial issues, such as the client's frustration and possible depression. They can assist with coping strategies, support services, and facilitating access to community resources.

Correct Answer is D

Explanation

Rationale:

A. Telling other nurses is useful for team morale but does not directly recognize the AP.

B. Detailing contributions to the manager is valuable but can be done after initial direct recognition.

C. Nominating for an award is an excellent formal recognition but should follow immediate feedback.

D. Giving direct positive feedback immediately acknowledges the AP’s efforts and encourages continued good performance.

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