A charge nurse is delegating care for a group of clients. Which of the following tasks should the charge nurse assign to a licensed practical nurse?
Perform a sterile dressing change for a client who has an abdominal wound.
Complete discharge teaching for a client who has a new diagnosis of diabetes mellitus.
Perform an admission assessment for a client who is scheduled for surgery.
Complete the Glasgow Coma Scale for a client who has an evolving stroke.
The Correct Answer is A
A. Correct. Performing a sterile dressing change falls within the scope of practice for a licensed practical nurse (LPN).
B. Incorrect. Discharge teaching often involves complex information and considerations, which are typically better suited for a registered nurse.
C. Incorrect. An admission assessment requires comprehensive assessment skills that are typically performed by registered nurses.
D. Incorrect. Completing assessments related to complex neurological changes, such as the Glasgow Coma Scale for a stroke, is typically within the scope of a registered nurse.
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Correct Answer is D
Explanation
A. Placing a pillow under the client's knees would not specifically address preventing a compromise in placental blood flow.
B. Reverse Trendelenburg involves tilting the bed so that the head is elevated and the feet are lower. While this position may help with respiratory difficulties (by allowing the diaphragm to expand), it does not address the concern of aortocaval compression, which is critical during pregnancy.
C. The lithotomy position is used for vaginal deliveries and involves placing the client's feet in stirrups, which is not appropriate for a cesarean birth.
D. The wedge position helps maintain blood flow to the placenta by relieving aortocaval compression, thereby improving venous return and placental perfusion. This is particularly important in pregnant clients, where the uterus can exert significant pressure on these blood vessels in the supine position.
Correct Answer is B
Explanation
A. Cyanosis, a bluish discoloration of the skin, may be more visible in areas where the skin is thinner. The sacrum is not reliable especially in the dark colored individuals.
B. Palms of the hand is reliable site for assessing for cyanosis.
C. Incorrect. Shoulders are not a common location to assess for cyanosis. Areas with thinner skin, such as the lips, oral mucosa, and nail beds, are usually observed for cyanosis.
D. Incorrect. Areas of trauma are not specifically used to assess for cyanosis. Cyanosis is a clinical sign that indicates inadequate oxygenation of the blood.
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