Author Question: The nurse is preparing to begin a physical examination for a patient with open lesions on the lower ... (Read 78 times)

crazycityslicker · **on:** Jul 23, 2018

The nurse is preparing to begin a physical examination for a patient with open lesions on the lower extremities. Which should the nurse evaluate during the physical assessment? (Select all that apply.)

a. Blood test results
b. X-ray results
c. Recent vital signs
d. Patient's health history
e. Subjective data

Question 2

The charge nurse is planning vital sign assignments for the unlicensed assistive personnel (UAP) on a busy medical-surgical unit. Which patients are appropriate for the UAP to obtain vital signs? (Select all that apply.)

a. A 28-year old patient scheduled to be discharged home today
b. A 49-year-old patient with stable chronic lung disease
c. A 78-year-old patient with recent onset of rectal bleeding
d. A 35-year-old patient waiting for transfer to a rehabilitation center
e. A 40-year-old patient being admitted from the emergency department

nyrave · **Reply #1 on:** Jul 23, 2018

Answer to Question 1

ANS: A, B, C
On completion of the patient interview, health history, and review of systems, the nurse begins the physical assessment. During the physical assessment, the nurse collects objective data. If diagnostic tests, such as blood tests or x-rays, were ordered before the patient was seen, the results are reviewed by the nurse. Vital signs are taken and recorded at the beginning of the physical examination.

Answer to Question 2

ANS: A, B, D
Routine assessment of vital signs of a patient who is stable may be delegated to Licensed Practical or Licensed Vocational Nurses (LPNs/LVNs) or qualified UAP. Initial and ongoing assessment of patients requiring critical care cannot be delegated to UAPs. Initial patient assessment of unstable patients cannot be delegated to LPNs/LVNs. LPNs/LVNs may contribute to the ongoing assessment of patients and document their observations and care. The patient with rectal bleeding needs critical care, and a new admission needs to be assessed by an RN. Stable patients such as the patient with stable lung disease, or awaiting discharge or transfer can be delegated to UAP.