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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is C

Explanation

Choice A reason: STIs do not typically cause abnormal PaCO2, which reflects respiratory or metabolic issues, unlike COPD’s impact on CO2 retention. Assuming STI is likely risks misdiagnosis, potentially delaying respiratory intervention, critical to avoid in ensuring accurate assessment and treatment based on arterial blood gas abnormalities in clients.

Choice B reason: CRF may cause metabolic acidosis, affecting pH, but PaCO2 is primarily respiratory, making COPD more likely. Assuming CRF is the cause risks overlooking airway issues, potentially delaying ventilation support, critical to prevent in ensuring precise diagnosis and management of abnormal PaCO2 in clients.

Choice C reason: COPD causes CO2 retention, elevating PaCO2 due to impaired gas exchange, a hallmark of respiratory acidosis, making it the likely diagnosis. Recognizing this is critical for timely respiratory interventions, ensuring oxygenation, preventing deterioration, and supporting accurate management of clients with abnormal arterial blood gas results.

Choice D reason: CHF may cause pulmonary edema, but PaCO2 is less directly affected than in COPD’s chronic CO2 retention. Assuming CHF is primary risks missing airway obstruction, potentially delaying respiratory care, critical to avoid in ensuring correct diagnosis and treatment of abnormal PaCO2 in clients.

A. Educating the client about her right to autonomy. B. Holding a family meeting and encouraging the client to speak on her own behalf. C. Respecting the client’s desire to have the uncle make choices on her behalf. D. Revisiting the decision when the uncle is not present at the bedside.

Correct Answer is C

Explanation

Choice A reason: Educating about autonomy may pressure the client, disregarding her cultural preference for family decision-making, undermining self-determination. Respecting her choice is key. Assuming education is best risks cultural insensitivity, potentially alienating the client, critical to avoid in ensuring culturally competent care for colorectal cancer clients.

Choice B reason: Encouraging the client to speak in a family meeting may conflict with her cultural deference to her uncle, compromising self-determination. Respecting her choice is appropriate. Assuming a meeting is best risks cultural imposition, potentially causing distress, critical to prevent in supporting client autonomy in cancer care.

Choice C reason: Respecting the client’s wish to defer to her uncle honors her cultural values and self-determination, ensuring decisions align with her preferences. This is critical for patient-centered care, supporting trust, cultural sensitivity, and informed choices, essential in managing colorectal cancer treatment decisions in diverse populations.

Choice D reason: Revisiting without the uncle disregards the client’s cultural preference, undermining self-determination. Respecting her choice to involve the uncle is correct. Assuming revisiting is best risks cultural insensitivity, potentially eroding trust, critical to avoid in ensuring autonomous, culturally appropriate care for colorectal cancer clients.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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 client’s PaCO2 is abnormal on an ABG report. What does the nurse suspect as the most likely medical diagnosis?

Correct Answer is C

Explanation

A client with a diagnosis of colorectal cancer has been presented with her treatment options, but wishes to defer any decisions to her uncle, who acts in the role of a family patriarch within the client’s culture. The client’s right to self-determination is best protected by

Correct Answer is C

Explanation

After starting a blood transfusion, the nurse notes that the patient has fever, chills, and facial flushing. What should be the nurse’s first step?

The client is in the intensive care unit following a stroke. The nurse is intervening in the plan of care to promote relaxation for the client and to prevent sensory overload. What independent nursing intervention would the nurse choose to do?

A nurse is reviewing a new order on the Electronic Health Record. The dose of the medication is abnormally high. What would be the nurse’s best next action?

Which client likely faces a risk for the nursing diagnosis of Disturbed Sleep Pattern: Difficulty Remaining Asleep?

A patient is admitted to the hospital with a diagnosis of alcoholism. The nurse should expect an order for

A nurse is discussing sleep problems with a client. What type of foods should the nurse recommend to promote sleep?

The nurse has just graduated with a Bachelor of Science in Nursing and is eager to find a mentor at this early stage in her career. Which of the following individuals is most likely to be an appropriate mentor for the nurse?

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)