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

Answer and Explanation

The Correct Answer is C

The correct answer is choice 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.

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Correct Answer is C

Explanation

This statement should be included in the hand-off report because it provides essential information about the patient’s intraoperative status and potential postoperative complications, such as hypovolemia, anemia, or infection. The estimated blood loss (EBL) is an important indicator of the patient’s fluid balance and hemodynamic stability.

Choice A is wrong because “The client was intubated without complications.” is not relevant for the postoperative care of the patient. The intubation status is usually documented in the anesthesia record and does not need to be repeated in the hand-off report unless there were any issues or injuries related to the airway management.

Choice B is wrong because “There was a total of 10 sponges used during the procedure.” is not pertinent for the postoperative care of the patient.

The number of sponges used during the surgery is usually counted and verified by the scrub nurse and the circulating nurse in the operating room to prevent any retained foreign bodies. This information does not need to be communicated to the PACU nurse unless there was a discrepancy or a missing sponge.

Choice D is wrong because “The client is a member of the board of directors.” is not appropriate for the hand-off report.

This statement violates the patient’s privacy and confidentiality and does not contribute to the quality or safety of care. The patient’s role or position in the organization should not influence the hand-off communication or the postoperative care.

A hand-off report is a critical communication tool that facilitates the transfer of care from one provider to another. It should include relevant information about the patient’s medical history, surgical procedure, intraoperative events, postoperative plan, and any concerns or potential problems.

A standardized hand-off tool, such as SBAR (Situation, Background, Assessment, Recommendation), can help improve the consistency, accuracy, and completeness of the hand-off report.

Some normal ranges that may be useful for postoperative care are:

Blood pressure: 90/60 mmHg to 120/80 mmHg
Pulse: 60 to 100 beats/min
Respiratory rate: 12 to 20 breaths/min
Oxygen saturation: 95% to 100%
Temperature: 36°C to 37.5°C
Hemoglobin: 12 to 18 g/dL
Hematocrit: 36% to 54%

A. Review the need for the indwelling urinary catheter daily. B. Place the drainage bag on the bed when transporting the client. C. Use soap and water to provide perineal care. D. Encourage the client to drink 3000 mL of fluid daily. E. Change the indwelling urinary catheter tubing every 3 days. F. Empty the drainage bag when it is half-full.

Correct Answer is ["A","C"]

Explanation

A: Review the need for the indwelling urinary catheter daily.
This is correct because indwelling catheters should be removed as soon as possible to reduce the risk of urinary tract infection (UTI).

B: Place the drainage bag on the bed when transporting the client.
This is incorrect because the drainage bag should be kept below the level of the bladder and should not touch the floor to prevent the backflow of urine and contamination of the catheter.

C: Use soap and water to provide perineal care.
This is correct because soap and water can help to remove bacteria and debris from the meatus and prevent infection.

D: Encourage the client to drink 3000 mL of fluid daily.
This is incorrect because the client has a fluid restriction of 1000 mL daily due to heart failure. Excessive fluid intake can worsen the client’s condition and increase the workload of the heart.

E: Change the indwelling urinary catheter tubing every 3 days.
This is incorrect because changing the catheter tubing can increase the risk of infection by breaking the closed drainage system. The catheter tubing should only be changed when it is visibly soiled or malfunctioning.

F: Empty the drainage bag when it is half full.
This is incorrect because the drainage bag should be emptied at least every 8 hours or when it is one-third full to prevent back pressure and infection.

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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?

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Naxlex Comprehensive Predictor Exams

A nurse in a PACU is transferring care of a client to a nurse on the medical-surgical unit. Which of the following statements should the nurse include in the hand-off report?

Correct Answer is C

Explanation

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.

Correct Answer is ["A","C"]

Explanation

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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?