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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Asking the family member to provide identification does not ensure that the caller is authorized to receive patient information. Even with identification, the nurse cannot verify the caller’s relationship to the patient or their authorization to access confidential information.
Choice B rationale
Not providing any information over the phone is the correct action to protect patient confidentiality. Healthcare providers must ensure that patient information is only shared with authorized individuals, and phone calls do not provide a secure method for verifying the caller’s identity.
Choice C rationale
Providing only publicly available information is not appropriate, as it still involves sharing patient-related details without proper verification. Any disclosure of patient information, even if minimal, must be done with caution and proper authorization.
Choice D rationale
Informing the family member that they need to visit in person is a better approach, but it still does not guarantee that the individual is authorized to receive patient information. The nurse should follow established protocols for verifying authorization before sharing any details.
Correct Answer is B
Explanation
Choice A rationale
The route of administration is important, but it is not the only missing element in this prescription.
Choice B rationale
The frequency of administration is missing, which is crucial for ensuring the medication is given at the correct intervals. Without this information, the prescription is incomplete and can lead to medication errors.
Choice C rationale
The patient’s name is essential, but it is not the only missing element in this prescription.
Choice D rationale
The prescriber’s signature is important for validating the prescription, but the frequency of administration is the critical missing element in this context.
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