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Soru

Zorluk: OrtaData Collection Techniques

A practical nurse (PN) is assigned to care for a diverse group of clients on a medical-surgical unit. Which of the following data collection and reporting actions by the PN demonstrate appropriate scope of practice and clinical understanding? Select all that apply.

  1. Palpating the uterine fundus to evaluate firmness and location on a client who is 24 hours postpartum.Cevap
  2. B
    Documenting sudden-onset confusion in an older adult client as an expected age-related change without notifying the registered nurse (RN).
  3. Evaluating pupillary light response as part of a focused neurological check for a client with a recent mild concussion.Cevap
  4. D
    Formulating a revised nursing care plan after auscultating newly developed bilateral lung crackles in a client with heart failure.
  5. Auscultating the apical pulse for one full minute before administering a scheduled oral dose of digoxin.Cevap
  6. F
    Withholding notification to the RN regarding a steadily increasing heart rate and decreasing blood pressure in a postoperative client because the values are borderline.

Cevap

The correct actions include palpating the postpartum uterine fundus, evaluating pupillary light response for a concussion client, and auscultating the apical pulse for a full minute before administering digoxin.
Within the practical nurse (PN) scope of practice, appropriate data collection involves focused, standardized techniques. Palpating the uterine fundus for firmness in a postpartum client, evaluating pupillary response in a client with a concussion, and auscultating the apical pulse for one full minute before giving digoxin are all examples of focused, task-oriented data collection techniques that fall safely within the PN's scope and ensure safe client care.

Adım Adım Çözüm

1
Analyze the role of the practical nurse (PN) in data collection across various clinical populations.
The PN is responsible for gathering focused physical data, performing specific vital sign techniques accurately, and recognizing abnormal findings to report to the registered nurse (RN).
Understanding the PN scope of practice helps separate appropriate data collection tasks from those requiring RN-level comprehensive assessment or clinical judgment.
2
Evaluate the correct actions based on the scope of focused data collection.
Palpating a postpartum fundus, checking a pupillary response, and auscultating an apical pulse for 60 seconds prior to digoxin administration are all focused, task-oriented techniques within the PN's scope.
These actions involve collecting specific data points for stable or predictable client conditions without requiring independent care plan formulation.
3
Identify the incorrect actions based on clinical traps and scope limitations.
Assuming sudden confusion is normal aging, revising a care plan independently, and ignoring borderline shock signs are incorrect actions.
Sudden confusion indicates delirium (often from infection), care plan revision is an RN duty, and borderline dropping vital signs in a postoperative client suggest early shock and require immediate reporting.

Anahtar Kavram

The practical nurse (PN) scope includes performing focused, task-oriented data collection and promptly reporting abnormal or changing conditions to the RN.
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Data Collection Techniques

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