A nurse on a surgical unit is caring for a group of clients. Which of the following is the priority action of the nurse?
Reassuring the partner of a client who sustained a closed head injury
Reinforcing a client's dressing for the surgical site of an above-the-knee amputation
Taking a telephone prescription about a client who is to be transferred from PACU
Assessing a client who experiences unilateral calf pain when ambulating
The Correct Answer is D
Rationale:
A. Reassuring the partner is important for emotional support but does not directly impact the immediate safety of clients.
B. Reinforcing a dressing is important for wound care but does not address urgent concerns.
C. Taking a telephone prescription is necessary but not as immediate as addressing a potential complication.
D. Assessing a client with unilateral calf pain is the priority as it may indicate a serious condition such as deep vein thrombosis (DVT), which requires immediate evaluation and intervention.
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Correct Answer is C
Explanation
Rationale:
A. Verify the AP's educational preparation prior to delegating the task is unnecessary if the AP has been trained and is competent in the task.
B. Observe the AP as she obtains the vital signs of each client is not required for routine tasks unless there is a concern about performance.
C. Determine the time frame the AP should report the results is crucial for ensuring timely and accurate reporting, which is necessary for effective patient care.
D. Ask the AP to take the vital signs of the client returning from surgery first might not be appropriate without considering the urgency of all clients’ conditions.
Correct Answer is C
Explanation
Rationale:
A. Providing appropriate resources is an outcome of effective delegation but not its primary purpose.
B. Promoting discharge teaching is not the primary purpose of delegation; it’s more about ensuring tasks are appropriately assigned.
C. Delegation permits a designated individual to meet a goal on your behalf, accurately reflecting the purpose of delegating tasks to others to achieve client care goals efficiently.
D. Decreasing health care costs may be an indirect benefit, but it is not the primary purpose of delegation.