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 ["A","C","E"]
Explanation
Choice A rationale
A patient who experiences postural hypotension is at a higher risk for falls. Postural hypotension, or a sudden drop in blood pressure upon standing, can cause dizziness and increase the likelihood of falling. This condition is common in older adults and those with certain medical conditions.
Choice B rationale
A patient who is experiencing nausea from chemotherapy is not necessarily at a higher risk for falls. While nausea can cause discomfort and weakness, it does not directly contribute to an increased risk of falling. Other factors, such as medication side effects or balance issues, are more significant in fall risk assessment.
Choice C rationale
A patient who has already fallen twice is at a higher risk for future falls. A history of falls is a strong predictor of subsequent falls, as it may indicate underlying issues such as balance problems, muscle weakness, or environmental hazards.
Choice D rationale
A patient who is older than 50 years old is not automatically at a higher risk for falls. While age is a factor, the risk significantly increases for individuals over 65 years old. Other factors, such as medical conditions and medication use, play a more critical role in fall risk assessment.
Choice E rationale
A patient who is transferred to long-term care is at a higher risk for falls. The transition to a new environment can be disorienting, and patients may be unfamiliar with their surroundings. Additionally, long-term care patients often have multiple health issues that contribute to an increased fall risk.
Correct Answer is B
Explanation
Choice A rationale
A respiratory therapist is not typically required to assist a stroke client with dysphagia. Their expertise is more focused on respiratory issues rather than swallowing difficulties.
Choice B rationale
A speech therapist is the correct team member to assist a stroke client with dysphagia. Speech therapists specialize in diagnosing and treating swallowing disorders, which are common in stroke patients.
Choice C rationale
A physical therapist focuses on improving a client’s physical mobility and strength. While they play a crucial role in stroke rehabilitation, they are not specifically trained to address dysphagia.
Choice D rationale
A pharmacist’s role is to manage and dispense medications. They do not have the specialized training required to assist with dysphagia.
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