The registered nurse is planning care to prevent venous thromboembolism in several clients

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When the nurse is caring for several clients on a medical surgical floor which task is appropriate to delegate to the unlicensed assistive personnel?
What client should the nurse assess first?
Which is a task that the nurse can delegate to the unlicensed assistive personnel UAP )?
Which client should the nurse assess first after receiving the shift report?

Nursing Interventions	Rationale
Assess level of consciousness and changes in mentation.	Initial signs of systemic hypoxemia include restlessness and irritability, followed by progressively decreased mentation.
Auscultate lungs for areas of decreased and absent breath sounds and the presence of adventitious sounds (crackles).	Non-ventilated areas may be identified by the absence of breath sounds. Crackles may be seen in fluid-filled tissues and airway or may indicate cardiac decompensation.
Monitor vital signs. Observe changes in cardiac rhythm.	Tachycardia, tachypnea, and BP changes are associated with progressing hypoxemia and acidosis. Alterations in heart rhythm and extra heart sounds may indicate increased cardiac workload related to worsening ventilation imbalance.
Assess respiratory rate and rhythm. Observe for use of accessory muscles, nasal flaring, and pursed lip breathing.	Tachypnea and dyspnea indicative of pulmonary obstruction. Dyspnea and increased work of breathing may be first or only sign of subacute pulmonary embolism. Severe respiratory distress and failure accompany moderate to severe loss of functional lung units.
Observe for generalized duskiness and cyanosis in the earlobes, lips, tongue, and buccal membranes.	Suggestive of systemic hypoxemia.
Assess activity tolerance, such as reports of weakness and fatigue, vital sign changes, or increased dyspnea during exertion. Encourage rest periods, and limit activities to client tolerance.	These guidelines help in determining the response of the client to resume activities and ability to engage in self-care.
Monitor the client frequently and arrange for someone to stay with the client, as indicated.	Provides assurance that changes in condition will be noted and that assistance is readily available.
Provide brief explanations of what is happening and expected effects of an intervention.	Relieves anxiety related to unknown and may help decrease fears regarding personal safety.
Encourage expression of feelings and inform the client and significant others of normalcy of anxious feelings and sense of impending doom.	Understanding basis of feelings may help the client regain some sense of control over emotions.
Assist with frequent changes of position, and encourage ambulation as tolerated.	Turning and ambulation enhance aeration of different lung segments, thereby improving oxygenation.
Encourage coughing, deep breathing exercises, and suctioning as indicated.	Increases oxygen delivery to the lungs by mobilizing secretions and enhancing ventilation.
Assist client to deal with the fear and anxiety that may be present.	Inability to breathe properly increases oxygen consumption and demand, therefore, worsening the anxiety level.
Keep the head of bed elevated.	Promotes maximal chest expansion, making it easier to breathe and enhancing physiological and psychological comfort.
Monitor ABGs or pulse oximetry.	Hypoxemia is present in varying degrees, depending on the degree of airway obstruction, cardiopulmonary status, and presence and degree of shock. Respiratory alkalosis and metabolic acidosis may also be present.
Prepare the client for a lung scan.	May reveal the pattern of abnormal perfusion in areas of ventilation, reflecting ventilation and perfusion mismatch, confirming the diagnosis of pulmonary embolism and degree of obstruction. Absence of both ventilation and perfusion reflects alveolar congestion or airway obstruction.
Assist with chest physiotherapy, such as postural drainage and percussion of the non-affected area and incentive spirometer.	Facilitates deeper respiratory effort and promotes drainage of secretions from lung segments into bronchi, where they may more readily be removed by coughing or suctioning.
Provide supplemental humidification, such as ultrasonic nebulizers.	Nebulization gives moisture to mucous membranes and helps liquefy secretions to facilitate airway clearance.
Provide oxygen therapy with an appropriate method as ordered.	Maximizes available oxygen for gas exchange, reducing work of breathing.
Provide adequate hydration either oral (PO) or IV as indicated.	Increased fluids may be given to decrease hyperviscosity of blood, which can potentiate thrombus formation, or support circulating volume and tissue perfusion.
Administer medications, as indicated:
Thrombolytic agents, such as alteplase (Activase, tPA), anistreplase (APSAC, Eminase), reteplase (Retavase), streptokinase (Kabikinase, Streptase), tenecteplase (TNKase) and urokinase (Abbokinase)	These agents intended to bring about clot lysis (breakdown of the clot) and immediate normalization of venous blood flow.
Morphine sulfate and anti-anxiety agents	These are given to decrease pain or anxiety and improve work of breathing., maximizing gas exchange.
Prepare for and assist with bronchoscopy.	The purpose of this procedure is to remove blood clots and clear the airway.
Prepare for surgical intervention, if indicated.	Vena caval ligation or insertion of an intracaval umbrella is intended for clients with recurrent emboli despite adequate anticoagulation, when anticoagulation is contraindicated, or when septic emboli arising from below the renal veins unresponsive to treatment; Pulmonary embolectomy is often done as a last resort treatment of PE.

When the nurse is caring for several clients on a medical surgical floor which task is appropriate to delegate to the unlicensed assistive personnel?

(Options 2 and 5) Client positioning and measurement of vital signs and pulse oximetry may be delegated to unlicensed assistive personnel (UAP).

What client should the nurse assess first?

A A A. Which client should the nurse assess first? The nurse should first assess the client showing symptoms of a deep venous thrombosis (DVT) (eg, unilateral edema , warmth, redness , tenderness on palpation).

Which is a task that the nurse can delegate to the unlicensed assistive personnel UAP )?

In general, simple, routine tasks such as making unoccupied beds, supervising patient ambulation, assisting with hygiene, and feeding meals can be delegated.

Which client should the nurse assess first after receiving the shift report?

Which client should the nurse on the vascular unit assess first after receiving the shift report? The client with an above the knee amputation who needs a full body lift to get in the wheelchair.

The registered nurse is planning care to prevent venous thromboembolism in several clients

When the nurse is caring for several clients on a medical surgical floor which task is appropriate to delegate to the unlicensed assistive personnel?

What client should the nurse assess first?

Which is a task that the nurse can delegate to the unlicensed assistive personnel UAP )?

Which client should the nurse assess first after receiving the shift report?

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