A nurse on a medical surgical unit has received report on four clients. There is an LVN, RN, and UAP working. Which of the following clients would best to assign to the RN?
Reinforcing teaching with a patient who is learning to walk with a quad cane
A new admission to the unit complaining of chest pain
Inserting an NGT for a client who is unable to eat
Calculating intake and output for the unit
The Correct Answer is B
A. Reinforcing teaching with a patient who is learning to walk with a quad cane: Reinforcing teaching can be done by an LVN, as it involves stable, predictable outcomes.
B. A new admission to the unit complaining of chest pain: A new admission with chest pain requires a comprehensive assessment and potential critical thinking and intervention, which are within the scope of an RN.
C. Inserting an NGT for a client who is unable to eat: Inserting an NGT can be done by an RN or LVN, but it does not require the comprehensive assessment and critical thinking that managing a new admission with chest pain does.
D. Calculating intake and output for the unit: Calculating intake and output is a task that can be delegated to a UAP.
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Correct Answer is B
Explanation
A. Give the client his blood pressure medication: Administering medications is outside the scope of practice for UAPs and should be done by licensed nursing staff.
B. Measure the vital signs: Measuring vital signs is within the scope of practice for UAPs and can be safely assigned to them.
C. Report any unusual lung sounds: Assessing and interpreting lung sounds require the skills and training of a licensed nurse.
D. Teach the patient about a heart-healthy diet: Teaching requires assessment and evaluation, which are within the RN’s scope of practice, not the UAP’s.
Correct Answer is B
Explanation
A. Primary prevention: Primary prevention involves measures taken to prevent diseases or injuries before they occur, such as vaccinations or health education to prevent onset of illness. Teaching blood sugar monitoring to someone with diabetes is not primary prevention.
B. Tertiary prevention: Tertiary prevention involves managing disease post-diagnosis to slow or stop disease progression. Teaching a diabetic patient to monitor their blood sugar helps manage their existing condition and prevent complications, making it tertiary prevention.
C. Secondary prevention: Secondary prevention includes screening and early detection of disease to halt or slow its progress. Monitoring blood sugar levels in a diabetic patient is not about early detection but managing an existing condition.
D. Disease surveillance: Disease surveillance involves continuous, systematic collection, analysis, and interpretation of health data. This is not what the nurse is doing when teaching a client to monitor their blood sugar.
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