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 client who is 3 days postoperative following a craniotomy
A client who is 3 days postoperative following gastric bypass surgery
A client who is 2 hr postoperative following an abdominal hysterectomy
A client who is 1 hr postoperative following a thyroidectomy
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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Correct Answer is C
Explanation
Rationale:
A. A client who is alert and oriented makes an informed decision to leave the hospital against medical advice. The nurse applies restraints to the client to prevent him from leaving constitutes a violation of patient autonomy and could be considered false imprisonment rather than negligence.
B. A nurse identifies the absence of peripheral pulsation in a casted extremity in the early morning and reports it to the provider in the early afternoon might be considered a delay in care but does not necessarily meet the criteria for negligence unless it leads to harm.
C. A client who is competent refuses an antidepressant medication. The nurse dissolves the medication in food and administers it to her without her knowledge is an example of negligence as it violates the client’s autonomy and informed consent.
D. A nurse finds a client who is on a low-sodium diet eating salted potato chips. The nurse tells the client that she will apply wrist restraints if he does not stop eating the potato chips is inappropriate but does not specifically represent negligence; it’s more about improper behavior or coercion.
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.