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 D

Explanation

Choice A rationale:

Bradycardia. Heparin is an anticoagulant medication that primarily affects the blood's clotting ability. Bradycardia, or a slow heart rate, is not a common side effect of heparin. Therefore, it is not a typical adverse effect to report in this context.

Choice B rationale:

Anorexia. Anorexia, or a loss of appetite, is not a common adverse effect of heparin. Heparin's primary mode of action is to prevent blood clot formation, and it does not directly affect appetite.

Choice C rationale:

Weight gain. Weight gain is not a typical adverse effect of heparin. Heparin's mechanism of action does not lead to changes in body weight. Weight gain could be related to other factors but is not directly associated with heparin administration.

Choice D rationale:

Epistaxis. Epistaxis, or nosebleeds, can be a sign of a bleeding disorder or an adverse effect of anticoagulant therapy like heparin. Heparin can increase the risk of bleeding, including nosebleeds, and should be monitored closely for this adverse effect. It is important to report any signs of excessive bleeding to the healthcare provider as they may need to adjust the dosage or monitor the patient more closely.

A. Elevates the legs before applying the stockings. B. Measures the client's calf circumference before selecting the stocking size. C. Applies lotion to the client's legs before putting on the stockings. D. Rolls down the stockings from the thigh to the ankle.

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

Explanation

A. Elevates the legs before applying the stockings: This is a correct action. Elevating the client's legs before applying elastic antiembolic stockings can help reduce swelling and improve blood flow. It's an appropriate step to prepare the client for the stockings.

B. Measures the client's calf circumference before selecting the stocking size: This is a correct action. Proper sizing of elastic antiembolic stockings is crucial to ensure they are effective and do not cause discomfort or complications. Measuring the client's calf circumference helps in selecting the right size.

C. Applies lotion to the client's legs before putting on the stockings: This is an incorrect action. Applying lotion to the legs before putting on stockings can make the stockings less effective and may cause them to slide down. Lotions or creams can create a barrier that interferes with the compression provided by the stockings.

D. Rolls down the stockings from the thigh to the ankle: This is an incorrect action. Elastic antiembolic stockings should be applied carefully, starting at the ankle and rolling them up to the thigh. Rolling them down from the thigh to the ankle is not the correct technique, as it can impede blood flow and be uncomfortable for the client.

So, the correct answers are A and B. These actions indicate that the AP is performing the skill correctly by preparing the client appropriately and ensuring proper sizing of the stockings.

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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 caring for a client who is 1 day postoperative following a total hip arthroplasty and is receiving heparin subcutaneously.Which of the following adverse effects of the medication should the nurse report to the provider?

Correct Answer is D

Explanation

A nurse is monitoring an assistive personnel (AP) who is applying elastic antiembolic stockings for a client who has phlebitis. Which of the following actions by the AP indicates that they are performing the skill correctly?

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

Explanation

A nurse is discussing the plan of care of a client who is 4 hr postoperative and has a urostomy with an assistive personnel. Which of the following statements should the nurse include in the discussion?

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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?