A nurse on a medical-surgical unit has received a report on four clients. Which of the following clients should the nurse assign to the RN?
Feeding a stroke client who has difficulty in swallowing.
Completing a sterile dressing change to a pressure ulcer.
Reapplying a condom catheter for a client with urinary incontinence.
Reinforcing teaching with a client who is learning how to administer insulin.
The Correct Answer is B
Choice A rationale
Feeding a stroke client who has difficulty in swallowing is a task that requires careful attention to prevent aspiration and choking. While this task is important, it can be delegated to a trained nursing assistant or a licensed practical nurse (LPN) under the supervision of an RN. The RN should focus on tasks that require higher levels of clinical judgment and expertise.
Choice B rationale
Completing a sterile dressing change to a pressure ulcer is a task that requires the expertise and clinical judgment of an RN. Sterile dressing changes involve maintaining a sterile field, assessing the wound, and applying appropriate dressings. This task is critical for preventing infection and promoting wound healing, making it appropriate for the RN to perform.
Choice C rationale
Reapplying a condom catheter for a client with urinary incontinence is a routine procedure that can be delegated to a trained nursing assistant or an LPN. This task does not require the advanced clinical skills and judgment of an RN, allowing the RN to focus on more complex and critical tasks.
Choice D rationale
Reinforcing teaching with a client who is learning how to administer insulin is an important task, but it can be delegated to an LPN under the supervision of an RN. The RN should prioritize tasks that require higher levels of clinical expertise and judgment, such as sterile dressing changes and complex assessments.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Tertiary prevention involves managing and rehabilitating patients with established diseases to prevent complications and improve quality of life. Referring a client to a specialist for further evaluation does not fit this category.
Choice B rationale
Primary prevention aims to prevent the onset of disease by reducing risk factors and promoting health. Referring a client to a specialist for further evaluation is not primary prevention.
Choice C rationale
Secondary prevention involves early detection and treatment of disease to prevent progression. Referring a client to a specialist for further evaluation fits this category as it aims to identify and address health issues early.
Choice D rationale
“Disease process” is not a recognized level of prevention. The correct levels are primary, secondary, and tertiary.
Correct Answer is B
Explanation
Choice A rationale
A Do Not Resuscitate (DNR) order is a type of advance directive that specifies that CPR should not be performed if the patient’s heart stops.
Choice B rationale
A trust fund is not a type of advance directive. It is a financial arrangement that does not relate to medical decisions.
Choice C rationale
A durable power of attorney for healthcare is a type of advance directive that allows an individual to appoint someone to make medical decisions on their behalf.
Choice D rationale
A living will is a type of advance directive that outlines an individual’s preferences for medical treatment in certain situations.
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