A nurse in a mental health facility is caring for a client who has a major depressive disorder.

Exhibits here

A nurse is planning to reinforce teaching with a client who is scheduled for a procedure. Which of the following statements should the nurse plan to make?

Select all that apply.

The charge nurse should explain to the assistive personnel (AP) that one of the responsibilities of a licensed practical nurse (LPN) is providing direct client care. LPNs work under the supervision of registered nurses (RNs) and are trained to deliver basic nursing care to clients. This includes tasks such as administering medications, monitoring vital signs, dressing wounds, assisting with activities of daily living (ADLs), and reporting any changes in the client's condition to the RN.

The other options are not typically within the scope of practice for an LPN:

a. Coordinating client care: The coordination of client care is primarily the responsibility of the RN. While LPNs may contribute to the coordination of care by providing input and collaborating with the healthcare team, the overall coordination is usually managed by the RN.

c. Assessing a client's health status: Assessing a client's health status is a role primarily performed by RNs. LPNs may gather data and contribute to the assessment process, but the comprehensive assessment and interpretation of data is typically the responsibility of the RN.

d. Identifying specific client health problems: Identifying specific client health problems and formulating nursing diagnoses is part of the RN's role. LPNs may assist in collecting data and providing input, but the identification and formulation of nursing diagnoses are within the scope of practice of the RN.

d. Remove the IV catheter.

Explanation:

The correct answer is d. Remove the IV catheter.

If the nurse realizes that the incorrect IV solution is infusing, it is essential to take prompt action to prevent harm to the client. Removing the IV catheter is the appropriate course of action to stop the infusion of the incorrect solution.

Option a, completing an incident report, may be necessary after the immediate situation has been addressed, but it should not be the nurse's first action. The priority is to stop the incorrect solution from infusing.

Option b, allowing the current solution to finish infusing and then changing the bag, is not the correct action. Continuing the infusion of the incorrect solution can potentially harm the client and must be stopped immediately.

Option c, documenting that an error occurred in the client's medical record, is important, but it should be done after taking immediate action to stop the incorrect solution from infusing. Documentation should include the details of the incident, any actions taken, and the client's response.

By promptly removing the IV catheter, the nurse stops the infusion of the incorrect solution and prevents further harm to the client. Afterward, the nurse should assess the client for any adverse effects, inform the appropriate healthcare providers, and follow the facility's policies and procedures for reporting incidents and documenting the error.