A nurse is assigning client care to an RN and an LVN. Which of the following tasks must they assign to an RN only and NOT to an LVN. All parts of the answer must be restricted to an RN only. (Select all that apply)

Creating a plan of care for a client who is recovering following a stroke.

Assessing a pressure injury on a client who is on bed rest.

Providing oral suctioning for a client who has pneumonia.

Administer internal feeding to a client who has a nasogastric tube.

Inserting a urinary catheter for a client who has urinary retention.

Answer and Explanation

Correct Answer : A,B

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.

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Correct Answer is D

Explanation

Choice A reason: Low Self Esteem involves negative self-perception, not spiritual questioning like “Why me, Lord?” which indicates psycho-spiritual distress. Assuming low self-esteem risks missing spiritual needs, potentially neglecting emotional support, critical to avoid in ensuring holistic care for dying clients expressing existential concerns.

Choice B reason: Anticipatory Grieving involves loss preparation, not spiritual crisis like inability to pray, which fits psycho-spiritual distress. Assuming grieving is correct risks overlooking spiritual turmoil, potentially delaying targeted interventions, critical to prevent in supporting dying clients’ emotional and spiritual needs in end-of-life care.

Choice C reason: Ineffective Coping involves maladaptive responses, not specific spiritual distress like questioning faith, which indicates psycho-spiritual distress. Assuming coping is the issue risks missing spiritual needs, potentially limiting holistic care, critical to avoid in addressing existential concerns in dying clients during end-of-life support.

Choice D reason: Psycho-spiritual Distress is appropriate, as the client’s crying, questioning “Why me, Lord?” and inability to pray reflect spiritual crisis. This diagnosis guides spiritual support, critical for emotional peace, ensuring holistic end-of-life care, and addressing existential concerns in dying clients facing terminal illness.

A. The patient identifies factors that interfere with normal sleep patterns. B. The patient reports minimal improvement in quality of rest and sleep. C. The patient verbalizes inability to sleep without medications. D. The patient reads in bed for several hours each night.

Correct Answer is A

Explanation

Choice A reason: Identifying sleep-interfering factors demonstrates effective care plan outcomes, empowering patients to address rest barriers, critical for sustained sleep improvement. This reflects nursing education success, ensuring proactive sleep management, supporting health, and promoting long-term rest strategies in clients with sleep difficulties in clinical settings.

Choice B reason: Minimal sleep improvement indicates ineffective care, unlike identifying sleep barriers, which shows progress. Assuming minimal improvement is a goal risks accepting suboptimal outcomes, potentially neglecting rest needs, critical to avoid in ensuring effective sleep promotion and care planning for clients with sleep issues.

Choice C reason: Inability to sleep without medications suggests dependency, not effective care, unlike identifying sleep barriers, which empowers patients. Assuming medication reliance is a goal risks poor sleep management, critical to prevent in ensuring non-pharmacological rest strategies and effective care outcomes for clients.

Choice D reason: Reading in bed for hours may disrupt sleep hygiene, unlike identifying barriers, which supports rest. Assuming reading is a positive outcome risks reinforcing poor habits, potentially worsening sleep, critical to avoid in ensuring effective care plans for promoting rest in clients with sleep difficulties.

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A nurse is assigning client care to an RN and an LVN. Which of the following tasks must they assign to an RN only and NOT to an LVN. All parts of the answer must be restricted to an RN only. (Select all that apply)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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?

Correct Answer is D

Explanation

Which expected outcome demonstrates the effectiveness of a plan of care to promote rest and sleep?

Correct Answer is A

Explanation

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