The charge nurse in an emergency center is planning client care assignments for the staff. Which action may be safely delegated to the practical nurse (PN)?
Provide client with resources and discharge teaching
Educate the clients about prescribed dietary changes.
Establish blood pressure parameters for client monitoring
Reinforce diet teaching for discharge to home
The Correct Answer is D
Choice A Reason: This action requires assessment and evaluation skills, which are beyond the scope of practice of the PN. The nurse is responsible for providing client education and ensuring that the client understands the discharge instructions.
Choice B Reason: This action requires teaching and evaluation skills, which are beyond the scope of practice of the PN. The nurse is responsible for educating the clients about their prescribed dietary changes and assessing their learning needs and readiness.
Choice C Reason: This action requires critical thinking and decision-making skills, which are beyond the scope of practice of the PN. The nurse is responsible for establishing the blood pressure parameters for client monitoring and adjusting them as needed.
Choice D Reason: This action can be safely delegated to the PN, as it involves reinforcing previous teaching done by the nurse. The PN can review the diet information with the client and answer any questions they may have.
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Naxlex Comprehensive Predictor Exams
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Correct Answer is D
Explanation
Choice A Reason: This assignment does not require immediate follow-up action by the charge nurse because a practical nurse can transport a stable postoperative client to another unit and report any changes or concerns to the primary nurse.
Choice B Reason: This assignment does not require immediate follow-up action by the charge nurse because a practical nurse can monitor the blood pressure of a client with hypertension and administer antihypertensive medications as prescribed and delegated by the primary nurse.
Choice C Reason: This assignment does not require immediate follow-up action by the charge nurse because a graduate nurse can obtain a unit of packed red blood cells from the blood bank and verify the compatibility and identification with another registered nurse before transfusing it to the client.
Choice D Reason: This is the correct answer because checking a client for fecal impaction is beyond the scope of practice of unlicensed assistive personnel. It involves inserting a finger into the rectum and assessing for hard stool, which can cause injury or infection to the client. The charge nurse should intervene and assign this task to a registered nurse or a practical nurse.
Correct Answer is B
Explanation
Choice A Reason: The initial administration of the analgesic is not an intervention that the charge nurse should counsel the nurse about. The opioid analgesic was prescribed by the healthcare provider and was appropriate for the postoperative pain management of the client.
Choice B Reason: The decision regarding when to call the healthcare provider is an intervention that the charge nurse should counsel the nurse about. The nurse should have called the healthcare provider as soon as the client's
respiratory rate decreased to 6 breaths/minute, which is a sign of opioid-induced respiratory depression. Waiting for another 30 minutes until the respiratory rate decreased to 4 breaths/minute could have put the client at risk of hypoxia, brain damage, or death.
Choice C Reason: The documentation of the client's respiratory rate is not an intervention that the charge nurse should counsel the nurse about. The nurse documented the client's respiratory rate accurately and timely, which is part of the standard of care and legal responsibility of the nurse.
Choice D Reason: The administration of naloxone via IV is not an intervention that the charge nurse should counsel the nurse about. Naloxone is an opioid antagonist that reverses the effects of opioids and restores normal respiration. Administering naloxone via IV is the fastest and most effective way to treat opioid-induced respiratory depression.
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