A charge nurse is making assignments for a group of clients.
Which of the following clients should the nurse assign to a licensed practical nurse?

A client who has a new diagnosis of diabetes mellitus and is awaiting teaching about meal planning.

A client who has a urinary output of 30 mL in the past hour.

A client who is postoperative following a hip arthroplasty and has a respiratory rate of 10/min.

A client who is newly admitted and requires an admission assessment.

Answer and Explanation

The Correct Answer is B

The correct answer is Choice B.

Choice A rationale: This client has a new diagnosis and requires initial teaching about meal planning, which is typically a responsibility of a registered nurse (RN) due to the need for specialized knowledge and teaching skills.

Choice B rationale: This client has a low urinary output, which needs to be monitored, but the care required is within the scope of practice of a licensed practical nurse (LPN). They can manage and report findings to the RN.

Choice C rationale: This client has a low respiratory rate postoperatively, which could indicate respiratory depression. This requires immediate assessment and intervention from an RN, who can make complex clinical judgments and initiate appropriate care.

Choice D rationale: This client needs an admission assessment, which includes comprehensive initial evaluation. An RN is required for this as it involves detailed assessment, care planning, and initiation of care.

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Correct Answer is C

Explanation

Choice A rationale:

Offering toileting opportunities every 1 to 2 hours is a reasonable intervention in a bladder training program, but it should not be the first action. Before establishing a toileting schedule, the nurse should assess the client's current voiding patterns to determine the most appropriate schedule based on the client's needs.

Choice B rationale:

Assisting the client with relaxation techniques can be beneficial in managing urinary incontinence or frequency, but it should not be the first action. Understanding the client's voiding pattern and any factors contributing to their urinary issues is essential before implementing relaxation techniques.

Choice C rationale:

Determining the client's pattern for voiding is the first step in developing a tailored bladder training program. This assessment helps identify the client's specific needs and enables the nurse to create a personalized plan that addresses their issues effectively.

Choice D rationale:

Discouraging intake of carbonated beverages is a valid intervention in managing urinary incontinence or frequency, but it should not be the first action. It's important to assess the client's individual habits and patterns before making dietary recommendations.

A. Decreased skin turgor. B. Decreased blood pressure. C. Weight loss. D. Crackles heard in the lungs.

Correct Answer is D

Explanation

Choice A rationale:

Decreased skin turgor. Decreased skin turgor is a sign of dehydration rather than fluid overload. In fluid overload, the body retains excess fluid, leading to symptoms like crackles in the lungs, edema, and increased blood pressure. Decreased skin turgor is more characteristic of dehydration, where the body loses fluid.

Choice B rationale:

Decreased blood pressure. Decreased blood pressure is not typically a manifestation of fluid overload. Fluid overload often leads to increased blood pressure as the heart has to work harder to pump excess fluid throughout the body.

Choice C rationale:

Weight loss. Weight loss is not a manifestation of fluid overload. In fact, fluid overload may lead to weight gain due to the retention of excess fluid in the body.

Choice D rationale:

Crackles heard in the lungs. Crackles heard in the lungs are a common manifestation of fluid overload. When there is an excessive accumulation of fluid in the lungs, it can interfere with the exchange of gases and cause crackling sounds during breathing. This is a significant clinical finding that indicates the need for intervention and assessment of fluid balance.

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A charge nurse is making assignments for a group of clients. Which of the following clients should the nurse assign to a licensed practical nurse?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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A charge nurse is making assignments for a group of clients.
Which of the following clients should the nurse assign to a licensed practical nurse?