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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 ["A","C","E"]

Explanation

Rationale:

A. Applying an ambulation alarm can help alert staff if the client tries to move independently, thus reducing the risk of falls.

B. Restraints should only be used as a last resort and require a physician’s order. They should not be used routinely for fall prevention.

C. Instructing the client in the use of the call light empowers them to request assistance, which can help prevent falls.

D. Raising all side rails can be considered a restraint and may increase the risk of falls or injury. It is not a recommended practice for fall prevention.

E. Checking on the client hourly ensures ongoing monitoring and timely intervention if needed, which is effective in preventing falls.

Correct Answer is C

Explanation

Rationale:

A. "I had strep throat about one year ago" is not directly related to contraindications for glyburide.

B. "I got my flu shot at the pharmacy two weeks ago" does not affect the use of glyburide.

C. "I plan to continue nursing my baby until he is at least a year old" indicates a contraindication because glyburide is not recommended for use during breastfeeding due to potential effects on the infant.

D. "I am allergic to shellfish" is not relevant to the contraindications for glyburide.

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