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.
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.
Administering internal feeding to a client who has a nasogastric tube.
Inserting a urinary catheter for a client who has urinary retention.
The Correct Answer is A
Choice A rationale
Creating a plan of care for a client recovering from a stroke requires comprehensive assessment, synthesis of complex data, and the establishment of nursing diagnoses and interventions. This falls within the scope of practice of a registered nurse who has the education and expertise in complex patient management.
Choice B rationale
Assessing a pressure injury involves observing and documenting wound characteristics. While an RN may perform this, an LVN, under the supervision of an RN, can also contribute to this task by collecting and reporting data about the wound.
Choice C rationale
Providing oral suctioning is a basic nursing skill that can be performed by both RNs and LVNs, following appropriate training and established protocols, to maintain airway patency for a client with pneumonia.
Choice D rationale
Administering internal feedings through a nasogastric tube is a task that can be delegated to an LVN who has received specific training and demonstrated competency, under the supervision of an RN, provided the client is stable and the feeding protocol is well-established.
Choice E rationale
Inserting a urinary catheter can be performed by both RNs and LVNs who have received the necessary education, training, and demonstrated competency in this invasive procedure, according to facility policies and state regulations.
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Correct Answer is D
Explanation
Choice A rationale
Hypokalemia, a deficiency of potassium in the blood (normal range: 3.5-5.0 mEq/L), typically leads to metabolic alkalosis due to intracellular hydrogen ion shifts. While respiratory and metabolic acid-base balances are interconnected, hypokalemia itself does not directly cause the retention of carbon dioxide, which is the hallmark of respiratory acidosis.
Choice B rationale
A high fever increases the metabolic rate, leading to increased oxygen consumption and carbon dioxide production. However, the body usually compensates for this by increasing the respiratory rate to expel the excess carbon dioxide. Therefore, while fever affects gas exchange, it is more likely to cause respiratory alkalosis due to hyperventilation, not acidosis.
Choice C rationale
Extreme anxiety can lead to hyperventilation, causing an excessive exhalation of carbon dioxide and a subsequent decrease in the partial pressure of carbon dioxide in the arterial blood (PaCO2). This results in respiratory alkalosis, not respiratory acidosis, where the PaCO2 is elevated (normal range: 35-45 mmHg).
Choice D rationale
Sedative overdose depresses the central nervous system, including the respiratory center in the brainstem. This depression leads to a decrease in both the rate and depth of breathing (hypoventilation). Inadequate ventilation causes the retention of carbon dioxide, leading to an increase in PaCO2 and a decrease in blood pH (normal range: 7.35-7.45), resulting in respiratory acidosis.
Correct Answer is B
Explanation
Choice A rationale
Locked-in syndrome is a rare neurological disorder characterized by complete paralysis of all voluntary muscles except for those that control eye movement. The client's reported symptoms of drowsiness, irritability, and decreased attention span do not align with the typical presentation of locked-in syndrome, where cognitive function remains largely intact.
Choice B rationale
Sensory deprivation occurs when there is a reduction in sensory input, leading to various psychological and physiological effects. The client's recent loss of regular visits from her daughter and family, coupled with the reported symptoms of drowsiness, excessive sleeping, decreased attention span, irritability, and signs of depression, strongly suggest sensory deprivation as a contributing factor due to reduced social interaction and stimulation.
Choice C rationale
Residential psychosis is not a recognized or well-defined psychological or psychiatric term. Therefore, it is not an appropriate diagnosis for the client's symptoms.
Choice D rationale
Disturbed sensory perception involves alterations in the processing of sensory stimuli, such as hallucinations or delusions. While the client exhibits changes in her mental state, the reported symptoms are more indicative of a lack of sensory input and social interaction rather than distorted sensory processing.
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