Author Question: Which action could the postanesthesia care unit (PACU) nurse delegate to unlicensed assistive ... (Read 112 times)

K@ · **on:** Jun 25, 2018

Which action could the postanesthesia care unit (PACU) nurse delegate to unlicensed assistive personnel (UAP) who help with the transfer of a patient to the clinical unit?

a. Clarify the postoperative orders with the surgeon.
b. Help with the transfer of the patient onto a stretcher.
c. Document the appearance of the patient's incision in the chart.
d. Provide hand off communication to the surgical unit charge nurse.

Question 2

A postoperative patient has a nursing diagnosis of ineffective airway clearance. The nurse determines that interventions for this nursing diagnosis have been successful if which is observed?

a. Patient drinks 2 to 3 L of fluid in 24 hours.
b. Patient uses the spirometer 10 times every hour.
c. Patient's breath sounds are clear to auscultation.
d. Patient's temperature is less than 100.4 F orally.

JYan · **Reply #1 on:** Jun 25, 2018

Answer to Question 1

ANS: B
The scope of practice of UAP includes repositioning and moving patients under the supervision of a nurse. Providing report to another nurse, assessing and documenting the wound appearance, and clarifying physician orders with another nurse require registered-nurse (RN) level education and scope of practice.

Answer to Question 2

ANS: C
One characteristic of ineffective airway clearance is the presence of adventitious breath sounds such as rhonchi or crackles, so clear breath sounds are an indication of resolution of the problem. Spirometer use and increased fluid intake are interventions for ineffective airway clearance but may not improve breath sounds in all patients. Elevated temperature may occur with atelectasis, but a normal or near-normal temperature does not always indicate resolution of respiratory problems.