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. Reinforcing discharge teaching is less critical during a disaster and should be secondary to addressing immediate needs.
B. Focusing on life-threatening emergencies aligns with the priorities in a disaster situation, where resources are limited.
C. Stocking additional supplies should be managed based on current needs and priorities but is not as urgent as immediate patient care.
D. Focusing on ADLs is important but not the priority when dealing with life-threatening situations.
Correct Answer is D
Explanation
Rationale:
A. A toddler with asthma and a pulse oximetry reading of 95% is stable and manageable with current oxygen therapy.
B. An adolescent with sickle cell disease is in pain but does not require immediate intervention compared to other scenarios.
C. A toddler with otitis media has a fever and discharge but is not in immediate danger.
D. A school-age child with acute epiglottitis is at high risk for airway obstruction and requires urgent care due to the drooling and absence of spontaneous cough, which are signs of a potentially life-threatening condition.