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
Refusing to administer the medication without further investigation could jeopardize the client's timely treatment. While safety is paramount, the nurse's initial action should be to gather more information rather than outright refusal, which could delay necessary care.
Choice B rationale
Administering a medication that appears to be abnormally high without verifying the order is unsafe and could lead to serious adverse effects for the client. Nurses have a professional responsibility to question orders that seem incorrect or potentially harmful.
Choice C rationale
Documenting concerns is an important step in the process, but it is not the best *next* action. While documentation is crucial for legal and communication purposes, directly addressing the potentially erroneous order with the prescriber takes precedence to ensure patient safety.
Choice D rationale
Querying the physician about the order is the most appropriate immediate action. This allows the nurse to clarify the dosage, route, and rationale for the high dose. It opens a dialogue with the prescriber to confirm the order's accuracy or identify a potential error, directly addressing the safety concern.
Correct Answer is A
Explanation
Choice A rationale
Battery in a legal context refers to the intentional touching of another person without their consent. Inserting a urinary catheter into a client's urethra after the client has explicitly refused the procedure constitutes a non-consensual physical contact. Even if the procedure was ordered, the lack of consent transforms the act into battery, especially if it results in injury to the client.
Choice B rationale
Dereliction of duty, a component of negligence, involves a failure to meet the accepted standard of care. While inserting a catheter against a client's will could be seen as a failure in ethical and potentially professional standards, the specific tort of battery focuses on the unauthorized physical contact, regardless of whether it was done negligently or with intent to harm (though intent to touch without consent is present).
Choice C rationale
Assault involves an intentional act that creates a reasonable apprehension of immediate harmful or offensive contact. While the client may have felt threatened or apprehensive when the nurse proceeded despite their refusal, the actual insertion of the catheter and subsequent injury constitute battery, as physical contact occurred. Assault precedes battery; battery is the actual physical contact.
Choice D rationale
Invasion of privacy pertains to the wrongful intrusion into a person's private affairs or the public disclosure of private information. While a client has a right to privacy regarding their body and medical procedures, the act of physically inserting a catheter against their will, leading to injury, primarily constitutes a physical violation and lack of consent, which falls under the definition of battery.
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