A nurse has assigned client care activities to an assistive personnel (AP). Which of the following statements by the AP Indicates a need for assistance in establishing priorities?

"I have my assignment and will start with room 1, then work my way to room 10."

"After breakfast, I will pack the belongings of clients who will be discharged this morning."

"I will start by providing partial baths before breakfast."

"I will give this client his meal tray first, as he is going early to physical therapy."

Answer and Explanation

The Correct Answer is A

Rationale:

A. Starting with room 1 and working to room 10 suggests a lack of prioritization based on client needs, which is important for efficient and effective care.

B. Packing belongings after breakfast is a reasonable plan, assuming it fits within the priorities of the shift.

C. Providing partial baths before breakfast might be acceptable depending on the client’s needs and the urgency of the task.

D. Giving a client their meal tray first based on their scheduled physical therapy is an example of prioritizing care based on client needs.

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Correct Answer is ["A","E"]

Explanation

A. While the client's temperature is not extremely high, it is elevated and persistent. Requesting an antipyretic or further evaluation may be warranted to prevent potential complications.

B. Insertion of NG tube for decompression is not necessary as the client is passing flatus and has bowel sounds in all quadrants, indicating normal gastrointestinal function.

C. Oxygen 2 to 4 L/min via nasal cannula is not necessary since the client's SpO2 levels are within normal range on room air.

D. The client's urinary output is adequate (400 mL over 6 hours), so a catheter is not required at this time.

E. The lack of drainage from the wound drain could indicate a problem that requires immediate attention. This could prevent complications like infection or fluid accumulation.

A. Agency policies for the LPN B. The documented experience level of the LPN C. The documented skill level of the LPN D. State Nurse Practice Act for the LPN

Correct Answer is D

Explanation

Rationale:

A. Agency policies for the LPN are important but secondary to ensuring the tasks fall within the scope of practice.

B. The documented experience level of the LPN is relevant but should be considered in conjunction with the scope of practice.

C. The documented skill level of the LPN is important for assigning tasks but must align with legal scope of practice.

D. State Nurse Practice Act for the LPN is the priority criterion as it defines the legal scope of practice and ensures that tasks delegated to the LPN are within their legal and professional boundaries.

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A nurse has assigned client care activities to an assistive personnel (AP). Which of the following statements by the AP Indicates a need for assistance in establishing priorities?

Nursing Test Bank

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