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 D
Explanation
Rationale:
A. Maintaining a client tracking system is crucial for managing large numbers of clients during a disaster.
B. Performing concise client assessment is essential for determining the severity of each client’s condition and prioritizing care.
C. Preventing cross-contamination of clients is important to prevent the spread of toxic substances.
D. Transferring a client to the discharge location is the lowest priority during a disaster, as immediate care and management of acute conditions take precedence over discharge planning.
Correct Answer is ["A","D"]
Explanation
Rationale:
A. Ambulate an older adult client who has hypertension is a task that an AP can perform, provided the client is stable and has been assessed by the nurse.
B. Provide discharge instructions for a client who has a new skin graft is a task that requires nursing judgment and cannot be delegated to an AP.
C. Check a blood product with another nurse prior to administration is a nursing responsibility that requires verification by licensed personnel and cannot be delegated to an AP.
D. Weigh a client who has heart failure is appropriate for an AP, as it involves routine measurement that can be delegated.
E. Perform an admission assessment on a client is a nursing responsibility and cannot be delegated to an AP.