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.
Nursing Test Bank
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Related Questions
Correct Answer is D
Explanation
Choice A rationale
Impaired Skin Integrity involves damage to the epidermal and/or dermal layers of the skin. While excessive fluid loss can indirectly affect skin turgor and increase the risk of breakdown over time, the primary and immediate physiological consequence of increased urinary output due to a diuretic is a potential reduction in overall fluid volume within the body, not a direct impairment of skin integrity.
Choice B rationale
Impaired Urinary Elimination describes difficulties in controlling or completely emptying the bladder. A diuretic, by its mechanism of action, increases urine production and thus promotes urinary elimination. While the *pattern* of elimination may change (increased frequency, urgency), the fundamental issue is not an impairment of the elimination process itself but rather an *increase* in it.
Choice C rationale
Urinary Retention is the inability to empty the bladder completely. A diuretic works to increase urine output, directly counteracting the physiological process of urinary retention. Therefore, this nursing diagnosis would be inappropriate for a client experiencing increased urinary output due to diuretic use.
Choice D rationale
Risk for Deficient Fluid Volume is a nursing diagnosis that identifies a vulnerability to a decrease in intravascular, interstitial, and/or intracellular fluid, which may compromise health. A diuretic increases urinary output, leading to a greater loss of fluid from the body. Without adequate fluid intake to compensate for this increased loss, the client is at a significant risk of developing a fluid volume deficit.
Correct Answer is D
Explanation
Choice A rationale
Dividing time evenly among patients reflects the professional value of justice, ensuring fair allocation of nursing resources based on patient needs rather than strict equality of time. Justice in nursing involves impartiality and equitable treatment.
Choice B rationale
Demonstrating care and concern for a patient's culture and beliefs aligns with the professional value of respect for autonomy and human dignity. It involves acknowledging and valuing the patient's individuality and their right to self-determination in healthcare decisions.
Choice C rationale
Encouraging the patient to make decisions about food selection promotes patient autonomy, allowing them to exercise their right to make choices about their care. This respects their preferences and empowers them in their healthcare journey.
Choice D rationale
Performing patient assessment and recording findings accurately exemplifies integrity, which involves honesty, truthfulness, and adherence to ethical principles. Accurate documentation provides an honest representation of the patient's condition and the care provided, crucial for safe and effective nursing practice.
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