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 B
Explanation
Choice A rationale
Ignoring the error, even if it does not affect patient care, is incorrect. Ignoring errors can lead to a culture of complacency and potentially more significant errors in the future. It is essential to address all errors to maintain accurate records and ensure patient safety.
Choice B rationale
Drawing a single line through the error, initialing, and dating it is the correct action. This method maintains the integrity of the medical record while clearly indicating that an error was made and corrected. It ensures transparency and accountability in documentation.
Choice C rationale
Leaving the error as is and informing the nurse manager is not the best practice. While informing the nurse manager is important, the error should be corrected in the medical record to prevent any potential confusion or miscommunication.
Choice D rationale
Erasing the incorrect entry and writing the correct one is incorrect. Erasing or obliterating entries in a medical record is not allowed as it can be seen as tampering with the record. It is crucial to maintain the original entry and make corrections transparently.
Correct Answer is A
Explanation
Choice A rationale
Facial expressions are indeed an example of non-verbal communication. Non-verbal communication includes body language, facial expressions, gestures, and eye contact. These cues can provide significant insights into a client’s feelings and attitudes.
Choice B rationale
Verbal communication is not always an accurate reflection of what the client really feels. Clients may sometimes say what they think the nurse wants to hear or may not fully express their true feelings verbally.
Choice C rationale
Nonverbal communication often reflects what the client is truly feeling more accurately than verbal communication. For example, a client may say they are not in pain, but their body language, such as grimacing or guarding a body part, may indicate otherwise.
Choice D rational
Body posture is an example of non-verbal communication, not verbal communication. Verbal communication involves spoken or written words, while non-verbal communication includes body language, facial expressions, and other physical cues.
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