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?

Perform a sterile dressing change for a client who has an abdominal wound.

Complete discharge teaching for a client who has a new diagnosis of diabetes mellitus.

Perform an admission assessment for a client who is scheduled for surgery.

Complete the Glasgow Coma Scale for a client who has an evolving stroke.

Answer and Explanation

The Correct Answer is A

A. Correct. Performing a sterile dressing change falls within the scope of practice for a licensed practical nurse (LPN).

B. Incorrect. Discharge teaching often involves complex information and considerations, which are typically better suited for a registered nurse.

C. Incorrect. An admission assessment requires comprehensive assessment skills that are typically performed by registered nurses.

D. Incorrect. Completing assessments related to complex neurological changes, such as the Glasgow Coma Scale for a stroke, is typically within the scope of a registered nurse.

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Correct Answer is D

Explanation

Choice A rationale:

An increase in heart rate by 10 beats per minute when moving from a supine to a sitting position is a normal physiological response to compensate for decreased venous return and maintain cardiac output. This response does not indicate orthostatic hypotension.

Choice B rationale:

An increase in diastolic blood pressure by 10 mm Hg when moving from a supine to a sitting position is a normal response to compensate for the effects of gravity on blood flow. It helps maintain perfusion to vital organs and does not indicate orthostatic hypotension.

Choice C rationale:

Heart palpitations can occur due to various reasons, including anxiety or arrhythmias, but they are not specific signs of orthostatic hypotension. This symptom alone does not confirm the presence of orthostatic hypotension.

Choice D rationale:

A decrease in systolic blood pressure by 25 mm Hg or more when moving from a supine to a sitting position indicates orthostatic hypotension. Orthostatic hypotension is defined as a drop in systolic blood pressure of 20 mm Hg or more or a drop in diastolic blood pressure of 10 mm Hg or more within 3 minutes of standing up. This condition can cause dizziness, lightheadedness, or fainting and can be a side effect of antihypertensive medications or other underlying medical conditions.

A. A client who is scheduled for a procedure in 1 hr B. A client who received a pain medication 30 min ago for postoperative pain C. A client who has 100 mL of fluid remaining in his IV bag D. A client who was just given a glass of orange juice for a low blood glucose level

Correct Answer is D

Explanation

A. A client who is scheduled for a procedure in 1 hr is not in immediate danger and can be assessed later.

A client who received a pain medication 30 min ago for postoperative pain may not need immediate assessment, unless there are signs of increased pain or other complications. The nurse can document the medication administration and observe the client’s response.
A client who has 100 mL of fluid remaining in his IV bag may not need immediate assessment, unless there are signs of fluid overload or electrolyte imbalance. The nurse can monitor the client’s fluid intake and output, weight, blood pressure, pulse, temperature, and laboratory values.
A client who was just given a glass of orange juice for a low blood glucose level need immediate assessment to reassess for persistent hypoglycemia

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is taking antihypertensive medication and is moving from a supine to a sitting position.Which of the following findings should indicate to the nurse that the client is experiencing orthostatic hypotension?

Correct Answer is D

Explanation

A nurse has just received change-of-shift report for four clients. Which of the following clients should the nurse assess first?

Correct Answer is D

Explanation

A nurse is caring for a client who has an indwelling urinary catheter. The nurse notes that sediment is present in the urine. Which of the following actions should the nurse take to obtain a sterile urine specimen?

A nurse is providing discharge teaching to a client who has GERD.Which of the following information should the nurse include?

A nurse is caring for a client in the medical-surgical unit. Exhibits Which of the following actions should the nurse take to decrease the risks for urinary tract infection for this client? Select all that apply.

A nurse is caring for a client who is 12 hr postpartum and has a third-degree perineal laceration. The client reports not having a bowel movement for 4 days. Which of the following medications should the nurse administer?

A nurse is planning care for a client who is scheduled for a thoracentesis. Which of the following actions should the nurse plan to take?

A nurse is teaching a class about providing care within the legal scope of practice to a group of nurses. The nurse should include that which of the following procedures is outside the legal scope of practice for an RN?

A nurse is providing teaching to a client who has a new prescription for enoxaparin. Which of the following medications for pain relief should the nurse include in the teaching that can be taken concurrently with enoxaparin?

A nurse is caring for a client who has experienced a stroke and is moving in with their adult child. Which of the following actions should the nurse encourage the client and family to take as they adjust to their new roles?