A nurse on an obstetrics-gynecology unit is planning care for four clients after receiving change of shift report. Which of the following clients should the nurse assess first?
A client who is 4 days postpartum and has mastitis
A client who had a bilateral tubal ligation 12 hr previously
A client admitted 1 hr ago for an ectopic pregnancy
A client who is a 1 day postpartum after a late term miscarriage
The Correct Answer is C
Rationale:
A. A client who is 4 days postpartum and has mastitis should be assessed, but this condition is less acute compared to the others.
B. A client who had a bilateral tubal ligation 12 hr previously requires post-operative monitoring, but this is less urgent than the client with an ectopic pregnancy.
C. A client admitted 1 hr ago for an ectopic pregnancy is the priority as this condition can be life-threatening and requires immediate assessment.
D. A client who is 1 day postpartum after a late-term miscarriage requires care, but the immediacy is less than that of the ectopic pregnancy client.
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Correct Answer is ["A","B","D"]
Explanation
Rationale:
A. Check the position of a client in soft wrist restraints is appropriate for an AP as it involves routine monitoring and ensuring the client's safety.
B. Accompany a client who has depression to occupational therapy is a task that can be assigned to an AP, as it involves providing support and ensuring the client's safe arrival to therapy.
C. Set limits with a client who has mania is not appropriate for an AP, as this involves therapeutic communication and behavior management, which requires nursing judgment.
D. Sit with a client who has alcohol use disorder and whose last drink was five days ago can be assigned to an AP as it involves providing a supportive presence and monitoring, but the nurse should assess for withdrawal symptoms.
E. Assess a client who has hypomania for exhaustion is a nursing responsibility that involves evaluation and judgment, making it inappropriate to delegate to an AP.
Correct Answer is A
Explanation
Rationale:
A. Performing blood glucose monitoring before breakfast is crucial for timely insulin administration and managing diabetes effectively.
B. Applying a condom catheter is important but can generally be done after more urgent tasks.
C. Delivering a clean urine specimen is important but less time-sensitive compared to blood glucose monitoring.
D. Feeding a client is important but may not be as urgent as tasks directly affecting medical management.