The nursing process guides nurses in delivery of care and includes sequential steps. Which step does the registered nurse (RN) perform within the nursing process that is not part of the standard of practice for the licensed practical nurse (LPN)?

Evaluation

Analysis

Implementation

Planning

Answer and Explanation

The Correct Answer is B

A. Evaluation:

Both RNs and LPNs engage in the evaluation step of the nursing process. It involves assessing the effectiveness of the care plan and determining whether the desired outcomes have been achieved.

B. Analysis:

The analysis step involves a deeper level of critical thinking and problem-solving. It often includes a more comprehensive examination and interpretation of assessment data to develop the nursing diagnosis, a step that typically falls within the scope of practice for RNs.

C. Implementation:

Both RNs and LPNs are involved in implementing the care plan, which includes carrying out nursing interventions according to the established plan of care.

D. Planning:

Both RNs and LPNs participate in the planning phase, which involves setting goals, establishing priorities, and creating a care plan tailored to the patient's needs.

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Correct Answer is D

Explanation

A. Placing the nurse's feet close together side by side to have a good center of gravity:

While maintaining a good center of gravity is important, in a falling situation, it's crucial to prioritize the client's safety over the nurse's stability. This option doesn’t address the prevention of the client’s fall.

B. Rocking the nurse's pelvis out and trying to hold the patient up to prevent falling:

Attempting to hold the patient up during a fall may put both the nurse and the client at risk of injury.

C. Grasping the gait belt and pushing the client’s body backward away from the nurse's body:

Pushing the client backward could cause the client to lose balance and fall in an uncontrolled manner.

D. Using the patient's gait belt to gently slide the client down the nurse's body to the floor:

This is the recommended action as it allows for a controlled descent to the floor, minimizing the impact of the fall and reducing the risk of injury to both the client and the nurse.

A. Discard the bottle of saline and obtain a new bottle B. Lip the battle of saline over the trash before pouring into the field C. Pour the saline at least 6 inches above the sterile field D. Be sure the label is facing the palm before pouring

Correct Answer is A

Explanation

A. Discard the bottle of saline and obtain a new bottle:

Sterility is crucial when performing a sterile procedure. If the saline solution has been opened for 48 hours, it may no longer be considered sterile. The nurse's priority is to use a fresh, sterile bottle of saline to ensure aseptic technique during the dressing change.

B. Lip the bottle of saline over the trash before pouring into the field:

Lipping the bottle over the trash is not a recommended practice. Pouring the saline over a sterile field is the appropriate way to maintain the sterility of the solution.

C. Pour the saline at least 6 inches above the sterile field:

While pouring from a height can help generate a flow without contamination, the priority in this situation is to address the sterility of the saline. It's crucial to start with a new, unopened bottle.

D. Be sure the label is facing the palm before pouring:

The orientation of the label is not the primary concern in this scenario. The primary concern is the sterility of the saline solution.

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The nursing process guides nurses in delivery of care and includes sequential steps. Which step does the registered nurse (RN) perform within the nursing process that is not part of the standard of practice for the licensed practical nurse (LPN)?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is ambulating a client who catches her foot on the bed frame and begins to fall. Which of the following is an accurate step to prevent or minimize damage from this fall?

Correct Answer is D

Explanation

The nurse on the progressive care unit is preparing to perform a sterile wet to dry dressing change on a client with a sacral pressure ulcer. The nurse notes that the sterile saline at the bedside is marked as opened 48 hours ago. What is the nurse’s priority action?

Correct Answer is A

Explanation

The nurse is admitting a patient with a suspected tuberculosis infection. Which type of isolation should the nurse institute for this client?

The nurse assists the client back to bed from the bedside commode. What is the most important action the nurse can take to assure client safety prior to leaving the room?

The nurse is providing oral care for a client who is weak, drowsy, and unable to take anything by mouth (NPO). Which of the following would the nurse implement when performing appropriate oral care for this client?

A nurse is administering enoxaparin 40mg subcutaneous to a client for prevention of blood clots when the client suddenly moves causing the needle to exit the client’s tissue and stick the nurse’s finger. What is the nurse’s first priority action?

A nurse is repositioning a client who has physical limitations due to recent back surgery. How often would the nurse turn the client in bed?

The nurse is caring for a client who has been on bed rest. The primary care provider has just written a new order for the client to sit in the chair three times a day. Which of the following is the best action to transfer the client, for the first time, safely into the chair?