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 B
Explanation
Rationale:
A. Removal of the nasogastric tube is a more complex task that typically requires the nurse’s assessment and judgment.
B. Monitoring vital signs is within the scope of tasks that can be assigned to assistive personnel. This task involves routine observation and does not require complex decision-making.
C. Application of antibiotic ointment requires specific knowledge about the condition and treatment, which is generally performed by a nurse.
D. Obtaining medical history information is a task that requires clinical judgment and interaction, and should be done by a nurse rather than an assistive personnel.
Correct Answer is ["A","B","C"]
Explanation
Rationale:
A. Verify the client understands the surgical procedure ensures the client is making an informed decision based on a clear understanding of the procedure, risks, and benefits.
B. Validate the signature is authentic is crucial to confirm that the consent form is genuinely signed by the client, indicating their agreement to proceed
.
C. Confirm that the consent is voluntary ensures that the client is not coerced into giving consent, upholding the principle of autonomy.
D. Explain the surgical procedure to the client is the responsibility of the surgeon or the provider, not the nurse. The nurse’s role is to witness the consent process and ensure that the client has been provided with and understands the information.
E. Establishing that the client is able to pay is not related to the informed consent process. Financial aspects are handled separately from the consent for treatment.