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 C
Explanation
Administer sublingual nitroglycerin.
Nitroglycerin is a vasodilator that can relieve chest pain caused by myocardial ischemia. The nurse should administer it as soon as possible to improve blood flow to the heart and reduce the risk of myocardial infarction. The nurse should also monitor the client’s blood pressure and heart rate after giving nitroglycerin, as it can cause hypotension and reflex tachycardia.
Choice A is wrong because checking a STAT cardiac troponin is not the first priority.
Cardiac troponin is a biomarker that indicates myocardial injury, but it may not rise until several hours after the onset of chest pain.
Therefore, it is not useful for immediate diagnosis or treatment of acute coronary syndrome. Choice B is wrong because requesting a prescription for a beta-blocker is not the first priority.
Beta-blockers are medications that can lower blood pressure and heart rate, and reduce the oxygen demand of the heart.
They can prevent or reduce the recurrence of chest pain and complications of acute coronary syndrome, but they are not indicated for immediate relief of chest pain.
Choice D is wrong because administering oxygen is not the first priority.
Oxygen therapy can increase the oxygen supply to the heart and reduce ischemia, but it is not necessary for all clients with chest pain.
Oxygen therapy should be based on the client’s oxygen saturation level and clinical condition.
If the client’s oxygen saturation is normal or high, oxygen therapy may not be beneficial and may even be harmful.
Correct Answer is A
Explanation
This is because at 12 weeks of gestation, the uterus is still low in the pelvis and the fetal heart tones are best audible through the fetal back, which is usually located just above the symphysis pubis. The fetal heart rate at this stage is normally between 120 and 180 beats per minute.
Choice B is wrong because measuring the fundal height is not necessary to determine the placement of the ultrasound stethoscope at 12 weeks of gestation. The fundal height is usually measured from 20 weeks of gestation onwards to assess fetal growth and estimate gestational age.
Choice C is wrong because placing the client in a side-lying position prior to assessing the fetal heart rate is not required at 12 weeks of gestation. This position may be helpful later in pregnancy to improve maternal blood flow and oxygen delivery to the fetus, especially if there are signs of fetal distress or hypoxia.
Choice D is wrong because performing Leopold maneuvers prior to auscultating the fetal heart rate is not appropriate at 12 weeks of gestation.
Leopold maneuvers are a series of four steps to palpate the abdomen and determine the fetal position, presentation, lie, and engagement. They are usually performed after 24 weeks of gestation when the fetus is large enough to be felt through the abdominal wall.
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