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 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.
Correct Answer is D
Explanation
Rationale:
A. Blood for PaCO2 is a specialized specimen that requires venipuncture and specific handling to ensure accuracy, which should be performed by a licensed nurse or phlebotomist.
B. Random stool specimen collection is a routine task that can be delegated to the AP. It requires minimal specialized skill and is within the AP's scope of practice.
C. Wound drainage for culture requires sterile technique and proper handling to avoid contamination, which is beyond the AP's responsibilities.
D. Urine from an indwelling catheter requires specialized techniques and knowledge to ensure proper collection, and should be performed by a nurse.