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 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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
Restlessness is a common indicator of unrelieved pain in a client. It suggests that the client is uncomfortable and experiencing discomfort, which could be due to inadequate pain relief. Restlessness may manifest as frequent shifting, fidgeting, and an inability to find a comfortable position. Therefore, choice A is the correct answer as it is a reliable indicator of unrelieved pain.
Choice B rationale:
Urinary retention is not typically associated with unrelieved pain in a client with a spinal epidural for a herniated disc. Urinary retention may result from the effects of the epidural anesthesia itself but is not a specific indicator of unrelieved pain. Therefore, choice B is not the correct answer.
Choice C rationale:
Constipation is not a direct indicator of unrelieved pain related to a spinal epidural. Constipation can occur for various reasons, including medications, decreased mobility, and dietary factors. While pain may contribute to constipation indirectly, it is not a reliable and specific sign of unrelieved pain in this context. Therefore, choice C is not the correct answer.
Choice D rationale:
Difficulty swallowing is not typically associated with unrelieved pain related to a spinal epidural. It may be related to other factors, such as muscle weakness or neurological issues, but it is not a specific indicator of unrelieved pain in this situation. Therefore, choice D is not the correct answer.
Correct Answer is A
Explanation
The correct answer is a. Plan to remove the restraints as soon as the client is calm.
Choice A reason: The primary goal after applying restraints is to ensure the safety of the client and others. Once the client is calm, planning for the removal of restraints is essential to maintain the client’s dignity and to adhere to ethical standards of minimizing restraint use.
Choice B reason: While offering snacks is part of general care, it is not specifically related to the immediate action required following the application of restraints. Nutritional needs should be addressed, but they do not take precedence over the assessment and potential removal of restraints.
Choice C reason: Ensuring that a prescription for restraints is signed within 48 hours is a legal requirement, but it is not the immediate action to be taken following the application of restraints. The focus should be on the client’s current state and reassessing the need for continued restraint.
Choice D reason: Monitoring the client’s range of motion every 60 minutes is important to prevent complications from restraint, such as contractures or muscle atrophy. However, this is secondary to the immediate reassessment of the need for restraint and planning for its removal as soon as the client is calm.
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