A nurse is delegating tasks to a team of staff members for a 65-year-old female patient who is post-op day 1 following a total knee replacement. The patient has stable vital signs (BP 130/85, HR 78 bpm, RR 18) and is ambulating with assistance. The nurse is considering delegating tasks to the LPN. Which of the following tasks can the nurse safely delegate to the LPN?

Assisting the patient with ambulation and evaluating pain level.

Administering prescribed medication and monitoring for side effects.

Performing a full head-to-toe assessment and identifying any complications.

Educating the patient on discharge instructions for post-operative care.

Answer and Explanation

The Correct Answer is B

Choice A reason: Evaluating pain level requires RN judgment, though assisting with ambulation is within the LPN’s scope. Medication administration is fully delegable, making this incorrect, as it includes an assessment task beyond the LPN’s role in post-operative care.

Choice B reason: Administering prescribed medication and monitoring for side effects is within the LPN’s scope, ensuring safe delegation. This aligns with post-operative care protocols, making it the correct task the nurse can safely delegate to the LPN for the knee replacement patient.

Choice C reason: A full head-to-toe assessment and identifying complications require RN expertise, exceeding LPN scope. Medication administration is appropriate, making this incorrect, as it’s an improper delegation for the nurse to assign to the LPN post-surgery.

Choice D reason: Educating on discharge instructions involves teaching and evaluation, an RN responsibility. Administering medication is within LPN scope, making this incorrect, as it’s not a safe task for the nurse to delegate to the LPN for the patient.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

Choice A reason: Pressuring the patient to proceed disregards her autonomy and right to revoke consent. Exploring her concerns respects her decision, making this incorrect, as it dismisses the patient’s expressed wish to cancel the mitral valve replacement surgery during transport.

Choice B reason: Highlighting rescheduling delays may coerce the patient, undermining her right to refuse. Addressing her fears validates her feelings, making this incorrect, as it prioritizes logistics over the patient’s autonomy and emotional state during the surgical consent process.

Choice C reason: Asking about the patient’s thoughts acknowledges her fear and respects her right to revoke consent, facilitating open communication. This aligns with ethical nursing practice, making it the correct response to support the patient’s decision regarding mitral valve replacement surgery.

Choice D reason: Dismissing the patient’s refusal with reassurance about medications ignores her autonomy and consent rights. Exploring her concerns is more appropriate, making this incorrect, as it fails to address the patient’s explicit wish to cancel the surgery during transport.

A. Place the client on a cardiac monitor. B. Notify the primary health care provider (PHCP). C. Put the client on NPO (nothing by mouth) status except for ice chips. D. Review the client’s medications to determine whether any contain or retain potassium. E. Allow an extra 500 mL of intravenous fluid intake to dilute the electrolyte concentration.

Correct Answer is ["A","B","D"]

Explanation

Choice A reason: A potassium level of 7.0 mEq/L risks lethal arrhythmias, necessitating cardiac monitoring. This aligns with hyperkalemia management, making it a correct priority action the nurse would plan to ensure the client’s safety and detect cardiac changes promptly.

Choice B reason: Notifying the provider is critical for a potassium level of 7.0 mEq/L, as urgent interventions like insulin or dialysis may be needed. This aligns with acute care protocols, making it a correct priority action for the nurse to address hyperkalemia.

Choice C reason: NPO status with ice chips is unrelated to hyperkalemia management, which focuses on lowering potassium. Cardiac monitoring is a priority, making this incorrect, as it’s not relevant to the nurse’s urgent actions for a client with severe hyperkalemia.

Choice D reason: Reviewing medications identifies potassium-containing or retaining drugs, preventing further elevation of 7.0 mEq/L. This aligns with hyperkalemia treatment, making it a correct priority action the nurse would plan to manage the client’s electrolyte imbalance effectively.

Choice E reason: Extra IV fluids (500 mL) may dilute potassium but risk fluid overload in acute kidney injury. Notifying the provider is more urgent, making this incorrect, as it’s not a priority compared to the nurse’s focus on immediate hyperkalemia interventions.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

During transport to the operating room for mitral valve replacement, a patient with a signed consent form says that she does not want to go through with the surgery and asks to be returned to her room. What is the best response from the nurse?

Correct Answer is C

Explanation

A client with acute kidney injury has a serum potassium level of 7.0 mEq/L (7.0 mmol/L). The nurse would plan which actions as a priority? (Select all that apply)

Correct Answer is ["A","B","D"]

Explanation

A client with exacerbation of chronic obstructive pulmonary disease (COPD) is scheduled for a thoracentesis. Which nursing intervention would be appropriate for client safety?

The nurse is providing dietary education to a client with gastroesophageal reflux disease (GERD). The nurse indicates that the client understands the teaching if the client states a plan to avoid which foods to prevent symptom exacerbation? (Select all that apply)

A client with chronic kidney disease being hemodialyzed suddenly becomes short of breath and complains of chest pain. The client is tachycardic, pale, and anxious, and the nurse suspects air embolism. What are the priority nursing actions? (Select all that apply)

After teaching a client with irritable bowel syndrome (IBS), a nurse assesses the client’s understanding. Which menu selection indicates that the client correctly understands the dietary teaching?

A nurse in an emergency department is caring for a client who has a blood pressure of 254/139 mm Hg. The nurse recognizes that the client is in a hypertensive crisis. Which of the following actions should the nurse take first?

A nurse is providing teaching to a client who has venous insufficiency of the lower extremities. Which of the following statements by the client indicates an understanding of the teaching?

The nurse is reviewing a client’s record and notes that the primary health care provider has documented that the client has chronic kidney disease. On review of the laboratory results, the nurse most likely would expect to note which finding?

A client admitted to the hospital with a suspected diagnosis of acute pancreatitis is being assessed by the nurse. Which assessment findings would be consistent with acute pancreatitis? (Select all that apply)