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 ["B","C","E","F"]

Explanation

A. Attends school regularly: While attending school regularly is important, it is not an immediate concern that requires follow-up compared to the other more pressing issues related to the traumatic event and the client's mental well-being.
B. Caregiver reporting client acting differently than usual: This finding requires immediate follow-up because it indicates a change in the client's behavior and could be indicative of emotional distress or mental health issues, especially considering the recent traumatic event they experienced.

C. Witnessing their family's death: Witnessing the death of family members in a traumatic event like a tornado is a significant and potentially traumatizing experience that requires immediate follow-up and support.
D. Heart rate 99/min: While a heart rate of 99/min is slightly elevated, it is not a critical finding that requires immediate follow-up in this context. The other findings are more relevant to the client's psychological well-being.
E. Smoking marijuana to clear their mind: The client's use of marijuana to cope with their thoughts and feelings should be addressed promptly, as it could indicate maladaptive coping mechanisms or potential substance abuse.
F. Client experiences nightmares: Experiencing nightmares could be a symptom of post-traumatic stress disorder (PTSD) or other mental health concerns related to the traumatic event.
G. BP 122/80 mm Hg: A blood pressure of 122/80 mm Hg is within a normal range and is not a cause for immediate concern.
H. Startles easy during thunderstorm: While startle responses can be related to anxiety, this specific finding is not as pressing as the client's reported coping mechanisms and traumatic experiences.

A. Maintain eye contact with the newborn during feedings. B. Swaddle the newborn with his legs extended. C. Minimize noise in the newborn's environment. D. Administer naloxone to the newborn.

Correct Answer is C

Explanation

A. Incorrect. While maintaining eye contact during feedings is generally beneficial for bonding, it's not a specific intervention for managing neonatal abstinence syndrome.

B. Incorrect. Swaddling a newborn with extended legs might be uncomfortable, as newborns with neonatal abstinence syndrome can experience increased muscle tone and jitteriness.
C. Correct. Newborns with neonatal abstinence syndrome can be hypersensitive to stimuli, including noise. Minimizing noise in the environment helps reduce stress and overstimulation.
D. Incorrect. Naloxone is not typically administered to newborns with neonatal abstinence syndrome. The syndrome is managed through supportive care, gradually reducing exposure to the substance.

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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

Correct Answer is ["B","C","E","F"]

Explanation

A nurse is developing a plan of care for a newborn whose mother tested positive for heroin during pregnancy. The newborn is experiencing neonatal abstinence syndrome. Which of the following actions should the nurse include in the plan?

Correct Answer is C

Explanation

A nurse is developing a plan of care for a client who has schizophrenia and is experiencing auditory hallucinations. Which of the following actions should the nurse include in the plan?

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