A nurse on the pediatric unit is providing room assignments for children who are to be admitted to the unit. The nurse should plan to place a child who is postoperative from an appendectomy with which of the following clients?
A child who is experiencing sickle cell crisis
A child who has a head injury
A child who has a new diagnosis of type 1 diabetes mellitus
A child who has streptococcal pharyngitis
The Correct Answer is C
Rationale:
A. A child who is experiencing sickle cell crisis may require isolation to prevent infection and avoid complications related to sickle cell disease.
B. A child who has a head injury may require specific monitoring and precautions that are not suitable for a postoperative appendectomy patient.
C. A child who has a new diagnosis of type 1 diabetes mellitus generally has a stable condition that can be managed with routine care and would be an appropriate roommate for a postoperative appendectomy patient.
D. A child who has streptococcal pharyngitis could pose an infection risk to the postoperative appendectomy patient and is better kept separate to prevent the spread of infection.
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Correct Answer is B
Explanation
Rationale:
A. "The client works in the hospital radiology department." This information is important for understanding the client's background but does not indicate a need for total care by the nurse.
B. "The client discussed having prior thoughts of suicide." This statement indicates a high-risk situation requiring close monitoring and direct care by the nurse, rather than delegating tasks to an AP. The client's safety and mental health status necessitate the nurse's full attention.
C. "The client's blood pressure and pulse have been fluctuating throughout the day." While this information suggests the need for monitoring, it doesn't necessarily preclude the AP from assisting with certain tasks under the nurse's supervision.
D. "The client's family members have been present most of the day." This statement provides context but does not indicate a need for total care by the nurse.
Correct Answer is D
Explanation
Rationale:
A. Assisting a client to cough and deep breathe is a task that can be performed by an AP under supervision.
B. Application of antiembolic stockings is within the scope of APs, though it may be monitored by an RN.
C. Administration of an enema typically requires nursing judgment and assessment, making it more appropriate for the RN.
D. Assessing a client’s sacrum for edema requires clinical assessment skills and nursing judgment, which should be performed by an RN.