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 newly admitted client who has diabetes mellitus and requires initial teaching on self- administration of insulin
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 infarction and will be transferring to the unit from the CCU.
The Correct Answer is B
- A: This client requires initial teaching, which is typically the responsibility of a registered nurse due to the educational aspect and the need to assess the client's understanding.
- B: Administering an enema is a task that falls within the scope of practice for a licensed practical nurse and does not require the advanced assessment skills of a registered nurse.
- C: Developing an initial plan of care involves comprehensive assessment and critical thinking, which are responsibilities of a registered nurse.
- D: A client transferring from the CCU after a myocardial infarction would require close monitoring and assessment, which are beyond the scope of practice for a licensed practical nurse.
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Correct Answer is D
Explanation
A. Mentioning that the client is the president of a local bank might not be pertinent to the client's current health status or care needs and is not typically included in a change-of- shift report unless relevant to the care plan.
B. The fact that the client's partner came to visit two hours ago might be important for emotional support or social interaction but might not be crucial information for the oncoming nurse unless relevant to the client's condition.
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. This is critical information for the incoming nurse. It informs them that the client is currently away from the unit, which may affect the plan of care, including monitoring, medication administration, or any interventions needed during the client’s absence. It is important for the incoming nurse to be aware of the client's current status and whereabouts.
Correct Answer is B
Explanation
A. Management of Type 1 diabetes with an insulin pump usually involves ongoing monitoring and adjustments but may not necessarily warrant an immediate interdisciplinary conference.
B. This client has a notable risk for pressure ulcers due to the albumin level, necessitating an interdisciplinary approach to prevent or manage these ulcers.
C. While monitoring heparin therapy is crucial, an aPTT of 34 seconds is within the therapeutic range and may not require an urgent interdisciplinary conference.
D. Orthostatic hypotension being managed with IV fluids may need ongoing assessment, but it may not warrant an immediate interdisciplinary conference.
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