Nokea
A nurse is caring for four postoperative clients. The nurse can delegate obtaining vital signs to an assistive personnel (AP) for which of the following clients?
- A. A client who is 3 days postoperative following a craniotomy
- B. A client who is 3 days postoperative following gastric bypass surgery
- C. A client who is 2 hr postoperative following an abdominal hysterectomy
- D. A client who is 1 hr postoperative following a thyroidectomy
Correct Answer: B
Rationale: The correct answer is B because a client who is 3 days postoperative following gastric bypass surgery is stable and unlikely to have immediate complications. Vital signs can be safely delegated to an assistive personnel (AP) for this client.
Choice A is incorrect because a client who is 3 days postoperative following a craniotomy may still be at risk for neurological complications that require close monitoring by a nurse.
Choice C is incorrect because a client who is only 2 hours postoperative following an abdominal hysterectomy is still in the immediate postoperative period and requires frequent monitoring by a nurse.
Choice D is incorrect because a client who is only 1 hour postoperative following a thyroidectomy is in the immediate postoperative period and may have potential complications that require close monitoring by a nurse.
Overall, the key factor in delegating obtaining vital signs to an AP is the stability of the client's condition postoperatively.
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A charge nurse is evaluating the performance of an assistive personnel (AP). Which of the following actions by the AP indicates a need for further education?
- A. The AP reports a client's temperature of 38.5°C to the nurse.
- B. The AP assists a client with turning every 2 hours.
- C. The AP leaves a client's meal tray out of reach after delivery.
- D. The AP uses a gait belt when ambulating a client.
Correct Answer: C
Rationale: Leaving the meal tray out of reach prevents the client from eating, indicating a need for further education on client-centered care. The other actions are appropriate.
A nurse on a medical-surgical unit is providing care for a group of clients. The nurse should delegate collection of which of the following specimens to the assistive personnel (AP)?
- A. Blood for PaCO2
- B. Random stool specimen
- C. Wound drainage for culture
- D. Urine from an indwelling catheter
Correct Answer: B
Rationale: The correct answer is B: Random stool specimen. The rationale is that collecting a random stool specimen does not require specialized training or skills, making it appropriate for assistive personnel (AP) to perform. Collecting blood for PaCO2 (A) requires specific training and knowledge of arterial blood gas sampling. Wound drainage for culture (C) involves sterile technique and knowledge of wound care. Urine from an indwelling catheter (D) requires knowledge of catheter care and sterile technique. Therefore, delegating the collection of a random stool specimen to AP is the most appropriate choice.
A charge nurse allows two nurses who are arguing about who gets to go to lunch first to go together. The charge nurse agrees to take care of both of the nurses' clients while they are at lunch. The charge nurse is demonstrating which of the following types of conflict management?
- A. Cooperating
- B. Compromising
- C. Avoiding
- D. Competing
Correct Answer: A
Rationale: The correct answer is A: Cooperating. The charge nurse is demonstrating cooperation by taking on the responsibility of caring for both nurses' clients while they go to lunch together. This approach shows a willingness to collaborate and find a solution that benefits all parties involved. By cooperating, the charge nurse is promoting teamwork and fostering a positive work environment.
Summary of other choices:
B: Compromising - This would involve finding a middle ground or making concessions, which is not the case in this scenario.
C: Avoiding - This would involve ignoring the conflict or avoiding confrontation, which is not what the charge nurse is doing.
D: Competing - This would involve a win-lose mindset where one party wins at the expense of the other, which is not evident in this situation.
A nurse is caring for a client who has a history of dementia. The client is alert and oriented to person, place, and time, and has advance directives. The client is scheduled for a procedure that requires informed consent. Which of the following persons should sign the informed consent?
- A. The client
- B. The client's son, who has a durable power of attorney
- C. The client's partner
- D. The client's daughter, who is the primary caregiver
Correct Answer: A
Rationale: The correct answer is A: The client. Informed consent must be given by the client themselves, as they are alert, oriented, and have advance directives. This ensures that the client fully understands the procedure, risks, benefits, and alternatives before giving consent. The client's autonomy and right to make decisions about their own healthcare are paramount. The other choices are incorrect because only the client themselves can provide informed consent in this scenario. The son with durable power of attorney may make decisions when the client is unable to, but since the client is alert and oriented, they should sign the consent. The partner and daughter do not have the authority to provide informed consent on behalf of the client.
A nurse is caring for a client who is experiencing a seizure. Which of the following actions should the nurse prioritize?
- A. Place the client in a high-Fowler's position.
- B. Insert a tongue depressor to prevent tongue biting.
- C. Protect the client from injury by clearing the area.
- D. Administer a prescribed anticonvulsant immediately.
Correct Answer: C
Rationale: Protecting the client from injury by clearing the area is the priority to ensure safety during a seizure. Positioning, tongue depressors, and medication administration are secondary or contraindicated.