The charge nurse is making assignments for a 15-bed skilled nursing unit with the staff of one nurse, two practical nurses (PN), and two unlicensed assistive personnel (UAP). Which client should be assigned to the PN?
The client who had bilateral above-knee amputations, now has a sacral decubitus skin flap, and is receiving vancomycin intravenously.
The client who is in end-stage Alzheimer's, who requires feeding, and is waiting for a long-term facility placement.
The client who has pneumonia following a total knee replacement, and is receiving clarithromycin orally.
The client who has right hemiplegia as the result of a cerebral vascular accident and receives continuous gastrostomy feedings per enteral pump.
The Correct Answer is C
The correct answer is c. The client who has pneumonia following a total knee replacement, and is receiving clarithromycin orally.
Choice A reason: This client has a complex wound care and an intravenous antibiotic therapy, which require the skills and knowledge of a registered nurse. Therefore, this client should not be assigned to a PN.
Choice B reason: This client has a chronic condition that does not require frequent assessment or intervention. Therefore, this client can be assigned to a UAP under the supervision of a nurse.
Choice C reason: This client has a stable condition that can be managed with oral medication and routine monitoring. Therefore, this client can be assigned to a PN who can administer oral drugs and report any changes to the nurse.
Choice D reason: This client has a high risk of aspiration and complications due to the enteral feeding and the neurological impairment. Therefore, this client should not be assigned to a PN.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: This client requires the PN's intervention, as she may have a psychological or physiological problem that affects her appetite and nutrition. The PN should assess the client's preferences, needs, and barriers, and provide appropriate interventions such as offering alternatives, supplements, or snacks, or consulting a dietitian or a social worker.
Choice B reason: This client can be assigned to the UAP, as long as they have been trained and supervised by the PN. The UAP should assist the client with feeding using the adaptive equipment, and encourage the client's independence and self-esteem.
Choice C reason: This client can be assigned to the UAP, as long as they have been trained and supervised by the PN. The UAP should assist the client with feeding in a slow and gentle manner, and monitor the client's swallowing and choking risk.
Choice D reason: This client can be assigned to the UAP, as long as they have been trained and supervised by the PN. The UAP should assist the client with feeding using soft and moist foods, and check the client's dentures for fit and cleanliness.
Correct Answer is C
Explanation
Choice A reason: Calling the client's next of kin and having them provide verbal consent is not the appropriate action for the nurse to take. The client is an adult and has the right to make his own decisions about his health care. The nurse should respect the client's autonomy and not involve his family without his permission.
Choice B reason: The nurse can reinforce information but cannot provide the primary explanation of the procedure. The HCP must clarify any confusion before consent is valid.
Choice C reason: Informed consent requires that the client fully understands the procedure, risks, benefits, and alternatives before signing. The healthcare provider (HCP) is responsible for explaining the procedure, not the nurse. Since the client’s question indicates misunderstanding, the nurse must notify the provider so they can clarify the information before consent is obtained.
Choice D reason: Postponing the procedure until the client understands the risks/benefits is not the best action for the nurse to take. The cardiac catheterization may be a time-sensitive and necessary procedure for the client's condition. The nurse should not delay the procedure without a valid reason. The nurse should try to enhance the client's understanding and confidence before postponing the procedure.
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