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 B
Explanation
Rationale:
A. The nurse does not relinquish accountability when delegating tasks to an AP; the nurse remains responsible for the overall care and outcomes.
B. Considering the AP's level of experience is crucial for effective delegation to ensure that tasks are matched to the AP's skills and knowledge.
C. Providing client education is generally beyond the scope of AP duties and should be performed by a licensed nurse.
D. Re-delegating tasks is not allowed; the original delegator remains responsible for ensuring the task is completed properly and should delegate directly to the appropriate individual.
Correct Answer is D
Explanation
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.