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.
The Correct Answer is C
Choice A rationale:
A client who has a new diagnosis of diabetes mellitus and is awaiting teaching about meal planning requires education and counseling about managing their condition, including meal planning and blood glucose monitoring. This client should be assigned to a registered nurse or an advanced practice nurse with expertise in diabetes care.
Choice B rationale:
A client who has a urinary output of 30 mL in the past hour may have an issue with urinary retention or inadequate fluid intake. This client needs immediate assessment and intervention, including monitoring urinary output and assessing for urinary retention. Assigning this client to a licensed practical nurse (LPN) may delay timely intervention.
Choice C rationale:
A client who is postoperative following a hip arthroplasty and has a respiratory rate of 10/min requires monitoring of vital signs and assessment for potential respiratory complications. While the respiratory rate is within the normal adult range, postoperative clients are at risk for respiratory issues, such as atelectasis or pneumonia. LPNs are qualified to monitor vital signs and assess for early signs of respiratory distress in stable postoperative clients.
Choice D rationale:
A client who is newly admitted and requires an admission assessment should be assigned to a registered nurse (RN) or an advanced practice nurse. The admission assessment typically involves a comprehensive evaluation of the client's physical and psychosocial health, including a detailed history and physical examination, which falls within the scope of practice of an RN.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
Hypercalcemia. Hypercalcemia refers to an elevated level of calcium in the blood. It is not typically a concern in a newborn, and monitoring for hypercalcemia is not necessary in this context. The infant's weight and maternal diabetes are more relevant factors to consider.
Choice B rationale:
Hypobilirubinemia. Hypobilirubinemia implies a low level of bilirubin in the blood, which is not a common concern in newborns, especially in the context of a newborn's weight and maternal diabetes. Monitoring for hyperbilirubinemia, which can lead to jaundice, would be more appropriate.
Choice C rationale:
Hypoglycemia. Hypoglycemia, or low blood sugar, is a significant concern in newborns of diabetic mothers. Newborns born to diabetic mothers are at increased risk of hypoglycemia due to the abrupt cessation of the continuous glucose supply from the mother's bloodstream after birth. Monitoring the newborn's blood glucose levels is crucial in this case.
Choice D rationale:
Decreased RBC. Monitoring for decreased red blood cell (RBC) counts is not typically a primary concern in a newborn, especially one born to a diabetic mother. Hypoglycemia, which can be a result of maternal diabetes, poses a more immediate and significant threat to the newborn's well-being.
Correct Answer is D
Explanation
Choice A rationale:
Identification is a defense mechanism where an individual associates themselves with another person or group. It does not apply to the situation described in the question.
Choice B rationale:
Reaction formation involves expressing the opposite of one's true feelings or desires. It is not the most suitable defense mechanism for the situation where the adolescent blames the teacher for their failure.
Choice C rationale:
Regression refers to reverting to an earlier stage of development in response to stress or conflict. It does not align with the adolescent's statement about their teacher disliking athletes.
Choice D rationale:
Rationalization is the defense mechanism in which a person provides logical or socially acceptable reasons for their behavior, even if these reasons are not accurate. In this case, the adolescent is rationalizing their poor performance by blaming the teacher's bias against athletes. This choice best fits the situation described.
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