The home health nurse is scheduling visits for clients with diabetes who need blood glucose measurements, one postoperative client who needs wound care, and two new clients who need admission assessments and care plans established. Staffing includes one nurse (RN) and two licensed practical nurses (PN). Which is the best home visit assignment?
RN completes the postoperative visit. Each PN completes one admission assessment and one blood glucose measurement.
RN completes the postoperative visit and two blood glucose measurements. Each PN completes one admission assessment.
CRN completes one admission and the postoperative visit. One PN completes the blood glucose measurements, one PN completes an admission assessment.
RN completes the two admission assessments. One PN completes the blood glucose measurements, and one PN completes the postoperative visit.
The Correct Answer is D
Brief introduction:
Nursing delegation and assignment are governed by the scope of practice defined by the Nurse Practice Act. The registered nurse (RN) is legally responsible for the nursing process, which includes complex clinical judgment, the formulation of care plans, and the initial assessment of unstable or newly admitted clients, while the licensed practical nurse (PN) focuses on stable clients with predictable outcomes.
Rationale:
A. Allowing a PN to complete an admission assessment is an inappropriate delegation of professional responsibility. Initial assessments and the development of a plan of care require the advanced diagnostic reasoning of an RN; assigning these tasks to a PN violates safety standards and clinical practice guidelines.
B. This assignment incorrectly utilizes nursing resources by tasking the RN with routine glucose monitoring while assigning high-complexity admissions to the PNs. The RN must prioritize tasks that cannot be delegated, specifically the initial evaluation of new clients, to ensure that the patient’s acuity level is accurately identified.
C. While the RN handles one admission, assigning the second admission to a PN remains a breach of scope. The PN is trained to collect data and perform standardized procedures, but they lack the legal authority to establish the initial nursing diagnoses or the comprehensive care goals required for a new home health admission.
D. The RN must complete both admission assessments because they involve complex decision-making and care plan establishment. Assigning the PN to perform wound care for a stable postoperative client and routine blood glucose measurements is appropriate delegation, as these tasks involve predictable outcomes and standardized clinical skills within the PN's technical training.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Nutritional screening is a systematic process used to identify individuals at risk of protein-energy malnutrition and those who may benefit from specialized metabolic support. These tools evaluate physiological variables such as unintentional weight loss, recent dietary intake reductions, and the metabolic stress induced by the client's current pathology. For high-acuity patients, effective screening facilitates early nutritional intervention, which is statistically linked to reduced hospital stay durations and improved wound healing.
Rationale:
A. The Subjective Global Assessment is a comprehensive clinical tool used to assess nutritional status based on patient history and physical examination findings. While highly effective for identifying severe malnutrition, it is a more labor-intensive assessment rather than a rapid screening tool for predictive outcomes. It does not utilize the specific scoring system found in the NRS-2002 protocol.
B. The Nutritional Risk Screening 2002 is the gold standard for identifying mildly-to-moderately malnourished clients in the acute care setting. It incorporates a nutritional score and a severity-of-illness score, making it uniquely capable of predicting clinical outcomes for critically-ill patients. This tool is specifically designed to determine which hospitalized patients require a formal nutrition plan.
C. The Mini Nutritional Assessment is a specialized screening tool validated almost exclusively for the geriatric population aged 65 and older. It focuses on age-related factors like mobility, neuropsychological problems, and polypharmacy, which are not applicable to a 25-year-old client. It is not the primary instrument used for predicting outcomes in younger critically-ill populations.
D. The Malnutrition Screening Tool is a simplified, two-question instrument often used in outpatient or general hospital wards to identify risk quickly. While efficient, it lacks the scientific depth to categorize malnutrition severity or provide predictive data for intensive care scenarios. It is generally used for initial identification rather than detailed outcome prediction in critical illness.
Correct Answer is ["B","C","E"]
Explanation
Brief introduction:
Nasogastric enteral nutrition requires strict adherence to safety protocols to prevent pulmonary aspiration and gastrointestinal distress. The nurse must ensure the gastrointestinal tract is ready to receive the bolus while maintaining anatomical positioning that utilizes gravity to facilitate gastric emptying. Precise management of the feeding infrastructure and the physical properties of the formula minimizes the risk of complications such as dumping syndrome or nosocomial pneumonia.
Rationale:
A. Diluting enteral formulas with water is generally contraindicated as it alters the caloric density and osmolality of the prescribed nutrition. Most formulas are designed to be administered at full strength to meet the specific metabolic demands of the patient. Dilution can lead to underfeeding and may introduce microbial contaminants if the water source is not sterile.
B. Elevating the head of the bed (HOB) to 30 to 45 degrees is a primary intervention to reduce aspiration risk. Maintaining this semi-Fowler position during and for 30 to 60 minutes after feeding prevents gastric reflux into the esophagus. This use of gravity is a standard evidence-based practice for any patient receiving nutrition via a gastric tube.
C. Verification of tube placement is the most critical safety step to prevent accidental tracheobronchial administration. The nurse must confirm the distal tip remains in the stomach using pH testing of aspirate or checking external markings against documented insertion lengths. Failure to verify placement before every intermittent feeding can lead to fatal pulmonary complications if the tube has migrated.
D. Enteral feeding is a clean, not sterile, procedure because the gastrointestinal tract is not a sterile environment. While the feeding container and tubing should be changed according to facility policy to prevent bacterial overgrowth, using expensive sterile containers is not clinically indicated. Clean technique is sufficient for the safe delivery of intermittent enteral nutrition.
E. Ensuring the feeding solution is at room temperature prevents gastric cramping and abdominal discomfort. Cold formula can cause rapid contraction of the gastric smooth muscle, leading to increased motility and diarrhea. Administering the solution at a temperate state promotes better tolerance of the bolus and enhances the overall comfort of the patient during the feeding.
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