The charge nurse is reviewing documentation completed by the registered nurse (RN) and evaluating the RN's delegation to the Licensed Practical Nurse (LPN) and Nurse aide (NA), as well as the RN's appropriate supervision.
Which medical record documentation indicates incomplete, unsafe, or inappropriate delegation? Select all that apply.
Client 4
Client 2
Client 3
Client 5
Client 1
Correct Answer : B,C,D
Rationale:
A. Client 4 is appropriate. The LPN administered oral Warfarin, which is within the LPN scope of practice. Providing a soft toothbrush by the CNA is also appropriate for a client on anticoagulation therapy to reduce bleeding risk. Delegation and supervision are appropriate in this scenario.
B. Client 2 is inappropriate. The RN documented insertion of a nasogastric tube (NGT) and verification of placement by chest x-ray. While RN actions are appropriate, the issue here is not delegation but documentation clarity—however, this scenario does not involve improper delegation to LPN or CNA. The question focuses on delegation errors, and this entry lacks clarity about supervision or role distribution in a complex intervention, making it incomplete in evaluating delegation and therefore problematic.
C. Client 3 is inappropriate. A CNA was sent to the blood bank to pick up a unit of packed red blood cells (PRBCs). This is unsafe and outside the CNA’s scope of practice. Handling blood products requires proper training and adherence to strict protocols, typically performed by licensed personnel. This represents inappropriate delegation.
D. Client 5 is inappropriate. The admission assessment was completed by an LPN. Comprehensive initial assessments for newly admitted clients must be performed by an RN, as they require clinical judgment and critical thinking. This represents inappropriate delegation of an RN responsibility.
E. Client 1 is appropriate. The CNA obtained vital signs and assisted the client with toileting using a bedpan. These tasks fall within the CNA’s scope of practice, and the RN appropriately supervised and documented the care.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Rationale:
A. Functional nursing is the most appropriate care delivery system in a situation where staffing is limited, such as during a winter storm. In functional nursing, tasks are divided among staff based on roles and skills rather than assigning care to specific patients. For example, one nurse might administer medications, another might handle vital signs, and UAPs may assist with hygiene and basic patient care. This method maximizes efficiency when there are fewer licensed nurses available to provide care to many patients.
B. Case management focuses on coordinating comprehensive care for patients across the continuum of care, often involving complex discharge planning, referrals, and collaboration with multiple disciplines. It is not practical in an acute staffing shortage because it requires more time and individualized attention than is feasible under minimal staffing conditions.
C. Primary nursing assigns one RN to oversee the total care of a patient from admission to discharge, with accountability for all aspects of care. This system requires adequate staffing and cannot be effectively implemented with only one RN and multiple patients, as continuity of care would be compromised.
D. Team nursing involves dividing patients among a team led by an RN, with LPNs and UAPs assisting. While normally effective, team nursing requires sufficient staff to form functional teams. In this scenario, the limited number of licensed staff (only one RN and two LPNs) makes true team nursing difficult to implement effectively.
Correct Answer is ["42"]
Explanation
Step 1: Identify total volume and time
Total volume = 250 mL, Time = 6 hours
Step 2: Use the formula
mL/hour = Total volume ÷ Time
Step 3: Insert values
= 250 ÷ 6
Step 4: Calculate
≈ 41.67 mL/hour
Step 5: Round to the nearest whole number
≈ 42 mL/hour
Final Answer: 42
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