A dying client is crying. She states, “Why me, Lord?” and “I can’t pray.” What would be the most appropriate nursing diagnosis based on this data?

Choice A reason: Creating a plan of care for a stroke client requires RN-level critical thinking, assessment, and prioritization, which are outside the LVN scope. RNs develop individualized plans based on complex patient needs, ensuring comprehensive recovery strategies. Assigning this to an LVN risks inadequate planning, potentially compromising stroke recovery outcomes, critical to avoid in nursing delegation.

Choice B reason: Assessing a pressure injury involves RN judgment to evaluate wound stage, complications, and treatment needs, beyond LVN scope. RNs ensure accurate staging and care adjustments, critical for preventing infection or deterioration. Assigning assessment to an LVN risks misdiagnosis or delayed intervention, potentially worsening outcomes, essential to prevent in wound care management.

Choice C reason: Oral suctioning for pneumonia is within LVN scope, as it is a technical skill not requiring complex assessment. RNs may perform it but can delegate to LVNs. Assuming RN-only assignment risks underutilizing LVN skills, potentially overburdening RNs, critical to avoid in efficient delegation while ensuring safe client care.

Choice D reason: Administering nasogastric tube feeding is a technical task within LVN scope, not requiring RN-only judgment. LVNs are trained to perform this safely under protocol. Assigning it to RNs only risks inefficient staffing, potentially delaying care, critical to prevent in ensuring timely nutrition delivery and balanced workload in nursing practice.

Choice E reason: Inserting a urinary catheter is within LVN scope in many states, as it is a standardized procedure not requiring RN-level assessment. Assuming RN-only assignment risks inefficient delegation, potentially delaying relief for urinary retention, critical to avoid in ensuring timely care and optimal staff utilization in nursing practice.

Choice A reason: Risk for Deficient Fluid Volume is appropriate, as diuretics increase urinary output, predisposing to dehydration, guiding education on fluid intake. This is critical for preventing hypovolemia, ensuring hydration, and supporting client safety, essential in managing diuretic therapy and promoting effective self-care in clinical settings.

Choice B reason: Impaired Skin Integrity relates to skin breakdown, not diuretic-induced urinary output, unlike deficient fluid volume risk. Assuming skin integrity is relevant risks misdirecting education, potentially neglecting hydration needs, critical to avoid in ensuring appropriate care planning for clients on diuretic therapy.

Choice C reason: Urinary Retention involves inability to void, opposite to diuretic effects, which increase output, making deficient fluid volume appropriate. Assuming retention is correct risks incorrect education, potentially confusing clients, critical to prevent in ensuring accurate care plans for diuretic-treated clients.

Choice D reason: Impaired Urinary Elimination involves dysfunctional voiding, not increased output from diuretics, unlike deficient fluid volume risk. Assuming elimination issues risks misguiding education, potentially overlooking dehydration, critical to avoid in ensuring proper nursing diagnoses and client education for diuretic therapy.