Question

The newly hired nurse is caring for a client who had a tracheostomy four hours ago. Which action by the nurse, if noted by the charge nurse, would cause the charge nurse to intervene?

a) The newly hired nurse delegates care of the tracheostomy to a licensed practical/vocational nurse (LPN/LVN).
b) The newly hired nurse assesses the client's pain and administers pain medication.
c) The newly hired nurse explains what she is doing and the reason to the client, even though the client does not appear to be alert.
d) The newly hired nurse adjusts the bed to a comfortable working position.

Answer 1

The action to be intervened is the delegation of care of a new tracheostomy to an LPN/LVN, as this task requires direct supervision of a registered nurse due to potential post-operative complications and the need for sterile procedures and advanced management skills.

Step-by-step explanation:

The action by the newly hired nurse that would cause the charge nurse to intervene is: a) The newly hired nurse delegates care of the tracheostomy to a licensed practical/vocational nurse (LPN/LVN). This action is likely to be intervened because the care of a newly placed tracheostomy generally requires the direct supervision of a registered nurse, especially within the first 24 hours post-procedure, when the risk of complications is highest. The LPN/LVN may not have the advanced training or scope of practice required to properly assess and manage potential complications that can arise in the immediate post-operative period.

Tasks in this critical period often include ensuring patency and proper placement of the tracheostomy tube, frequent monitoring of vital signs, and emergency management skills which are typically within the registered nurse's scope of practice, not the LPN/LVN. Therefore, it is imperative that the registered nurse retains responsibility for this care to ensure accurate and sterile procedures are followed, and patient safety is maintained.