A nurse is delegating care for a group of clients. Which of the following clients should the nurse assign to a licensed practical nurse?
A client who is scheduled for an endoscopy later today and requires an enema
A newly admitted client who has sickle cell anemia and requires the development of an initial plan of care
A client who had a myocardial infraction and will be transferring to the unit from the CCU
A newly admitted client who has diabetes mellitus and requires initial teaching on self- administration of insulin
The Correct Answer is A
a. A client who is scheduled for an endoscopy later today and requires an enema:
Administering an enema involves basic nursing care, which falls within the scope of practice of an LPN. LPNs are trained to perform such tasks under the supervision of a registered nurse (RN).
b. A newly admitted client who has sickle cell anemia and requires the development of an initial plan of care:
Developing an initial plan of care involves comprehensive assessment, critical thinking, and the ability to formulate nursing diagnoses and interventions. This task typically falls within the scope of practice of the RN, who has advanced education and training in care planning and coordination.
c. A client who had a myocardial infarction and will be transferring to the unit from the CCU:
Transferring a client from one unit to another may involve coordinating care, ensuring continuity of care, and communicating with other members of the healthcare team. This task may be more appropriate for an RN, who has the knowledge and skills to manage such transitions safely and effectively.
d. A newly admitted client who has diabetes mellitus and requires initial teaching on self-administration of insulin:
Providing client education, especially on self-care management such as insulin administration, requires knowledge of disease processes, medication administration, and patient teaching techniques. This task is typically within the scope of practice of the RN, who can assess the client's learning needs, provide tailored education, and evaluate the client's understanding and competency.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
a. Providing a 10-minute rest period prior to meals:
This action is not specifically related to feeding technique for clients with dysphagia. While providing a rest period before meals may be beneficial for some clients, especially those who experience fatigue or dyspnea, it is not a standard technique for managing dysphagia during mealtime.
b. Elevating the head of the client’s bed to 30 degrees during mealtime:
The head of the bed should be elevated to at least 45–90 degrees during meals to minimize the risk of aspiration. A 30-degree elevation is insufficient for safe swallowing and increases the likelihood of aspiration.
c. Instructing the client to place her chin toward her chest when swallowing:
This technique, known as the chin-tuck maneuver, helps reduce the risk of aspiration in clients with dysphagia by improving airway protection and directing food and liquid down the esophagus instead of the trachea. It is a widely recommended method to promote safe swallowing.
d. Withholding fluids until the end of the meal:
Fluids should not be withheld until the end of the meal as they are often necessary to help the client swallow food safely and prevent choking. Thickened fluids may be prescribed for clients with dysphagia to aid in safe swallowing.
Correct Answer is A
Explanation
a. “The client is in the radiology department for a chest x-ray.”
This information is relevant as it informs the oncoming nurse about the client's current location and the reason for the absence from the unit. It helps maintain awareness of the client's whereabouts and the ongoing diagnostic process.
b. “The client’s partner came to visit him 2 hrs. ago.”
While it's important to document visitor interactions in the client's chart, informing about a visit from 2 hours ago during a change-of-shift report may not be as pertinent to immediate patient care as other information. This detail can be communicated through other means, such as the client's chart or communication log.
c. “The client has routine vital signs prescribed.”is not as critical to include in the change-of-shift report because it is standard practice and does not provide specific, immediate information about the client’s current status or any changes that need to be monitored closely.
d. “The client is the president of a local bank.”
While interesting, this information is not relevant to the client's current medical condition or care plan. It does not contribute to the immediate care needs of the client and can be considered extraneous during a change-of-shift report.
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