The charge nurse, working with one nurse, two practical nurses (PNs), a unit secretary, and two unlicensed assistive personnel (UAPs), is caring for 24 clients on a medical surgical unit. Which task is best for the charge nurse to assign to the PN?
Transcription of the healthcare provider's treatment plan for a client transferred from a critical care unit.
The subclavian dressing change on a client diagnosed with inflammatory bowel disease.
The admission assessment of a client diagnosed with bacterial pneumonia.
The insertion of a Foley catheter for a client diagnosed with septicemia.
The Correct Answer is D
Choice A reason: Transcription of the healthcare provider's treatment plan is not a task that can be delegated to a PN, as it requires nursing judgment and documentation. The charge nurse should perform this task and verify the orders with the provider.
Choice B reason: A subclavian catheter dressing change is a sterile procedure involving central line care, which is considered an advanced skill typically performed by an RN. Many facilities do not allow PNs to perform this due to the risk of infection and complications.
Choice C reason: The admission assessment is not a task that can be delegated to a PN, as it involves collecting and analyzing data from multiple sources. The charge nurse or the registered nurse should perform this task and document the findings.
Choice D reason: PNs are trained and authorized to insert Foley catheters, which is within their scope of practice. Although the patient has septicemia, catheter insertion is a task-based procedure that does not require critical decision-making, making it an appropriate assignment for a PN.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: The client post triple coronary bypass four days ago who has serosanguinous drainage in one chest tube is not the most urgent client to check. The client may have some bleeding and inflammation from the surgery, but the condition is not life-threatening or unstable. The client requires routine care and monitoring of the chest tube and the wound.
Choice B reason: The client admitted yesterday with diabetic ketoacidosis whose blood glucose level is now 195 mg/dL (10.8 mmol/L) is not the most urgent client to check. The client may have improved from the initial presentation of high blood glucose, acidosis, and dehydration, but the condition is not life-threatening or unstable. The client requires education, fluid replacement, and insulin administration.
Choice C reason: The client with an ileal conduit created two days ago with a scant amount of blood in the drainage pouch is not the most urgent client to check. The client may have some postoperative complications such as infection, obstruction, or leakage, but the condition is not life-threatening or unstable. The client requires observation, comfort measures, and stoma care.
Choice D reason: The client with a pneumothorax secondary to a gunshot wound with a current pulse oximeter reading of 90% is the most urgent client to check. The client has a serious and unstable condition that requires chest tube insertion and oxygen therapy. The client is at risk of respiratory failure, hypoxia, or tension pneumothorax and needs to be assessed and treated as soon as possible.
Correct Answer is A
Explanation
Choice A reason: Telling the healthcare provider the nurse will return the phone call as soon as possible is the best instruction for the nurse to provide the unit clerk. The nurse is responsible for receiving and verifying the prescription from the healthcare provider and cannot delegate this task to the unit clerk. The nurse should prioritize the unstable client and call back the healthcare provider when the situation is stable.
Choice B reason: Remaining with this client and monitoring the vital signs while the nurse takes the call is not the best instruction for the nurse to provide the unit clerk. The nurse should not leave the unstable client unattended and should not rely on the unit clerk to perform the nursing assessment and intervention. The nurse should also not take the call from the healthcare provider without verifying the identity and authority of the caller.
Choice C reason: Asking the healthcare provider to remain on "hold" until the nurse can confirm the prescription is not the best instruction for the nurse to provide the unit clerk. The nurse should not keep the healthcare provider waiting on the phone and should respect the healthcare provider's time and availability. The nurse should also not confirm the prescription without receiving and verifying it from the healthcare provider.
Choice D reason: Being sure to write down what is prescribed and then repeat it back to the healthcare provider is not the best instruction for the nurse to provide the unit clerk. The nurse should not allow the unit clerk to receive and transcribe the prescription from the healthcare provider and should not delegate this task to the unit clerk. The nurse should also not assume that the unit clerk has the knowledge and skills to understand and communicate the prescription.
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