A charge nurse is delegating care for a group of clients.
Which of the following tasks should the charge nurse assign to a licensed practical nurse?
Complete discharge teaching for a client who has a new diagnosis of diabetes mellitus.
Complete the Glasgow Coma Scale for a client who has an evolving stroke.
Perform a sterile dressing change for a client who has an abdominal wound.
Perform an admission assessment for a client who is scheduled for surgery.
The Correct Answer is C
Perform a sterile dressing change for a client who has an abdominal wound. This is because a licensed practical nurse (LPN) can perform tasks that require technical skills and have predictable outcomes, such as dressing changes. A sterile dressing change is also within the scope of practice of an LPN.
Choice A is wrong because complete discharge teaching for a client who has a new diagnosis of diabetes mellitus requires assessment, evaluation and critical thinking, which are beyond the scope of practice of an LPN. Discharge teaching is the responsibility of a registered nurse (RN) who can provide education and counseling to clients and families.
Choice B is wrong because completing the Glasgow Coma Scale for a client who has an evolving stroke requires assessment and interpretation of neurological status, which are complex and unpredictable tasks that only an RN can perform. The Glasgow Coma Scale is a tool that measures the level of consciousness of a client based on eye opening, verbal response and motor response. A client who has an evolving stroke may have changes in their neurological status that require frequent monitoring and intervention by an RN.
Choice D is wrong because performing an admission assessment for a client who is scheduled for surgery requires comprehensive data collection, analysis and synthesis, which are advanced skills that only an RN can perform. An admission assessment involves obtaining a complete health history, performing a physical examination, identifying client needs and problems, and developing a plan of care.
A client who is scheduled for surgery may have complex and unpredictable needs that require specialized knowledge and judgment by an RN.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
This instruction will help the client to prevent venous stasis and thrombosis, which are common postoperative complications. Range-of-motion exercises promote blood circulation and prevent muscle atrophy and contractures.
Choice B is wrong because “Use an incentive spirometer every 4 hours.” is wrong because it is not related to promoting circulation, but rather to improving lung expansion and preventing atelectasis and pneumonia. Using an incentive spirometer is also important for postoperative clients, but it does not address the question.
Choice C is wrong because “Remain on bed rest for 24 hours following the procedure.” is wrong because it is the opposite of promoting circulation.
Bed rest increases the risk of venous stasis, thrombosis, and pulmonary embolism. Postoperative clients should be encouraged to ambulate as soon as possible, unless contraindicated.
Choice D is wrong because “Place a pillow under your knees while in bed.” is wrong because it also impairs circulation and increases the risk of thrombosis.
Placing a pillow under the knees can cause pressure on the popliteal veins and reduce blood flow. Postoperative clients should avoid this position and keep their legs in a neutral or slightly elevated position.
Correct Answer is D
Explanation
This means that the client knows who they are, where they are, and what time it is. This indicates a high level of consciousness and a normal Glasgow coma scale (GCS) rating of 15.
Choice A is wrong because the client withdraws from pain.
This means that the client reacts to a painful stimulus by pulling away from it. This indicates a lower level of consciousness and a GCS rating of 4 for motor response.
Choice B is wrong because the client is unable to obey commands.
This means that the client does not follow simple instructions such as moving a limb or opening their eyes. This indicates a lower level of consciousness and a GCS rating of 1 or 2 for motor response.
Choice C is wrong because the client opens eyes to sound.
This means that the client does not open their eyes spontaneously, but only when they hear a loud noise. This indicates a lower level of consciousness and a GCS rating of 3 for eye opening.
The Glasgow coma scale is a clinical tool used to assess the level of consciousness of a person after a brain injury.
It consists of three tests: eye opening, verbal response, and motor response.
Each test has a score range from 1 to 6, with higher scores indicating higher levels of consciousness. The total score ranges from 3 to 15, with lower scores indicating higher risk of death.
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