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A nurse on a medical-surgical unit is delegating client care. Which of the following tasks should the nurse delegate to assistive personnel?
- A. Instructing a client on self-administration of a tap water enema
- B. Suctioning a client's long-term tracheostomy
- C. Performing a dressing change on a client's peripherally inserted central catheter
- D. Using a pain rating scale to monitor a client's pain level
Correct Answer: D
Rationale: The correct answer is D: Using a pain rating scale to monitor a client's pain level. This task can be safely delegated to assistive personnel as it involves non-invasive monitoring that does not require specialized medical knowledge. Assistive personnel can accurately record the pain level reported by the patient without interpreting or making clinical decisions based on the information. In contrast, choices A, B, and C involve invasive procedures or specialized skills that require clinical judgment and assessment, making them inappropriate for delegation to assistive personnel. Choice D allows the nurse to focus on more complex nursing assessments and interventions while ensuring the client's pain is monitored effectively.
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A nurse is caring for a client who has uterine prolapse. The provider has recommended a total abdominal hysterectomy, but the client tells the nurse that the surgery is not an option. Which of the following is an appropriate action for the nurse to take?
- A. Discuss with the client her concerns regarding the procedure.
- B. Initiate a mental health consult to determine the client's reasons for refusing surgery.
- C. Provide the client with information on treatment options and outcomes.
- D. Inform the client of the consequences of uterine prolapse and the need for intervention.
Correct Answer: A
Rationale: Correct Answer: A: Discuss with the client her concerns regarding the procedure.
Rationale:
1. Building Trust: By discussing the client's concerns, the nurse shows empathy and builds trust.
2. Client Autonomy: Respecting the client's decision-making process is essential.
3. Informed Decision-Making: Understanding the client's fears helps in providing tailored information.
4. Collaboration: Discussing concerns opens the door for shared decision-making.
5. Holistic Care: Addressing emotional aspects is crucial for overall well-being.
Incorrect Choices:
- B: Initiating a mental health consult may be premature and could undermine the client's autonomy.
- C: Providing information without addressing concerns may not address the root of the refusal.
- D: Informing the client without understanding her perspective may lead to increased anxiety and resistance.
Exhibit 1 Nurses' Notes 1315:
Client is postoperative following an open cholecystectomy, Client's partner is at bedside. Surgical dressing intact, with small amount of serosanguineous drainage on dressings. Client reports pain as 5 on a scale of 0 to 10. Client requests a dose of their pain medication. Client expresses concern regarding the cost of prescription medications. Client reports being unable to find transportation to follow-up appointment
Plan of Care
1300:
Case management referral for discharge planning.
Client will need home health referral for dressing changes Client to follow up with the provider at the clinic in 1 week.
A nurse case manager is reviewing the electronic medical record of a postoperative client. Click to highlight the findings that require follow-up by the case manager.
- A. Client reports being unable to find transportation to follow-up appointment
- B. Client expresses concern regarding the cost of prescription medications
- C. Case management referral for discharge planning
- D. Client will need home health referral for dressing changes
Correct Answer: A
Rationale: []
Rationale:
- Correct Answer (A): The client reporting being unable to find transportation to the follow-up appointment is a critical issue that requires immediate follow-up by the case manager to ensure continuity of care and adherence to the treatment plan.
- Incorrect Answer (B): Although concerns about the cost of prescription medications are important, they do not directly relate to the immediate follow-up needed postoperatively.
- Incorrect Answer (C): Case management referral for discharge planning is essential but does not specifically address the immediate follow-up after the postoperative period.
- Incorrect Answer (D): While the client needing a home health referral for dressing changes is important, it does not pertain to the immediate follow-up that the case manager needs to address.
A nurse preceptor is observing a newly hired nurse perform a sterile dressing change. Which of the following actions should the nurse preceptor identify as maintaining sterile technique?
- A. Uses a sterile-gloved hand to adjust the back of the sterile gown
- B. Uses sterile forceps to pack sterile gauze into the wound
- C. Places sterile gauze 1.3 cm (0.5 in) away from the edge of a sterile drape
- D. Sets up the sterile field 30 min prior to performing the dressing change
Correct Answer: B
Rationale: Using sterile forceps to pack gauze maintains sterility, reducing infection risk, unlike actions that breach sterile field integrity.
A client scheduled for a tubal ligation procedure starts to cry as she is wheeled into the surgical suite. Which of the following nursing statements is an appropriate nursing response?
- A. It's not too late to cancel the surgery if you want to.
- B. This won't take long and it will be over before you know it.
- C. Why did you make the decision to have this procedure?
- D. You shouldn't be worried because the procedure is very safe.
Correct Answer: A
Rationale: Correct Answer: A. "It's not too late to cancel the surgery if you want to."
Rationale: This response acknowledges the client's emotions and empowers her to make a decision based on her feelings. It shows empathy and respect for her autonomy in making choices about her own body.
Summary of Other Choices:
B: This response dismisses the client's emotions and may come off as insensitive.
C: Asking why the client made the decision can be perceived as judgmental and may increase anxiety.
D: This response invalidates the client's feelings and may not provide reassurance effectively.
A nurse working on a medical-surgical unit is managing the care of four clients. The nurse should schedule an interdisciplinary conference for which of the following clients?
- A. A client who has orthostatic hypotension and is receiving IV fluids
- B. A client who is receiving heparin and has an aPTT of 34 seconds
- C. A client who has Type 1 diabetes and uses an insulin pump
- D. A client who is at risk for pressure ulcers and has an albumin level of 4.2 g/dL
Correct Answer: D
Rationale: Pressure ulcer risk and nutritional concerns require interdisciplinary collaboration (e.g., dietitian, physical therapist) for comprehensive care.