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 ["B","D","E","F"]

Explanation

Choice A rationale:

Performing intermittent external electronic fetal monitoring is not the best choice in this situation. The client’s condition, which includes severe abdominal pain, vaginal bleeding, rigid and tender abdomen, and late decelerations in the fetal heart rate, suggests a possible placental abruption. In such a case, continuous fetal monitoring is required to closely monitor the fetal heart rate and contractions.

Choice B rationale:

Monitoring vital signs at least every 15 min is necessary. The client’s blood pressure has dropped from 110/68 mm Hg to 95/59 mm Hg within 15 minutes. This could indicate hypovolemia due to blood loss. Regular monitoring can help detect changes early and initiate appropriate interventions.

Choice C rationale:

Placing the client in a supine position is not recommended. This position can exacerbate supine hypotensive syndrome, which occurs when the gravid uterus compresses the inferior vena cava, reducing venous return and cardiac output. A side-lying position would be more appropriate.

Choice D rationale:

Obtaining a type and crossmatch is crucial. The client’s symptoms suggest a possible placental abruption, which can lead to significant blood loss. Having blood available for transfusion can be lifesaving.

Choice E rationale:

Measuring blood loss by weighing pads can provide an objective assessment of blood loss. This can help guide treatment decisions, including the need for blood transfusion.

Choice F rationale:

Inserting a large-bore IV catheter is necessary in this situation. It allows for rapid fluid and blood replacement if needed. Given the client’s symptoms and the potential for significant blood loss with placental abruption, this intervention is appropriate.

A. Preferred bath time. B. Admission vital signs. C. Time of last pain medication. D. Steps required for dressing change.

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

Explanation

The correct answers are C and D.

Choice A reason: Preferred bath time is a personal preference and comfort-related aspect of patient care. While it is important for overall patient satisfaction and care planning, it is not critical information for a change-of-shift report following a total knee arthroscopy. The focus in such reports is typically on clinical status, immediate care needs, and potential complications.

Choice B reason: Admission vital signs are the initial measurements taken upon the patient’s admission to the healthcare facility. These are baseline values that can be referenced later to note any significant changes. However, for a change-of-shift report, especially 2 days postoperative, the most current vital signs and any changes since surgery are more pertinent than the admission values.

Choice C reason: The time of the last pain medication is crucial information for a change-of-shift report. Pain management is a key aspect of postoperative care, particularly after procedures like total knee arthroscopy. Knowing when the last dose was administered helps the incoming nurse manage the patient’s pain effectively and anticipate when the next dose is due.

Choice D reason: The steps required for dressing change are essential to include in the change-of-shift report. Proper wound care and dressing changes are vital to prevent infection and ensure proper healing after surgery. Detailed instructions on the dressing change process help maintain consistency in care between different caregivers.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assisting with the care of a client who presents to the labor and delivery unit. Exhibits The nurse assisting with this client's care should expect which of the following prescriptions from the client's provider? Select all that apply.

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

Explanation

A nurse is preparing to give change-of-shift report on a client who is 2 days postoperative following a total knee arthroscopy. Which of the following information should the nurse include in the report? (Select all that apply)

Correct Answer is ["C","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?