A nurse is delegating care for a group of clients. Which of the following clients should the nurse assign to the LPN?

A client who is scheduled for an endoscopy later today and requires an enema

A newly admitted client who has sickle cell anemia and requires the development of an initial plan of care

A client who had a myocardial infarction and will be transferring to the unit from the CCU

A newly admitted client who has diabetes mellitus and requires initial teaching on self-administration of insulin

Answer and Explanation

The Correct Answer is A

Rationale:
a.   Administering an enema for a scheduled endoscopy is within the scope of practice for an LPN. It involves a task that is repetitive, stable, and does not require critical thinking.
b.   Developing an initial plan of care for a client with sickle cell anemia involves critical thinking and assessment, which are within the scope of practice for an RN.
c.   A client transferring from the CCU after a myocardial infarction requires close monitoring and assessment, which are typically within the scope of practice for an RN.
d.   Teaching a newly admitted client about self-administration of insulin involves education, assessment, and critical thinking, which are typically within the scope of practice for an RN.

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Correct Answer is C

Explanation

A. Postoperative urinary retention is common after surgery, especially within the first 12 hours. While this requires monitoring and possible intervention, it is not the highest priority.
B. Emotional distress before surgery is important to address, but it is not an immediate physiological concern requiring urgent intervention.
C. An absent pulse in the right foot indicates potential acute arterial occlusion, which is a medical emergency. This condition can lead to tissue ischemia and necrosis if not treated promptly. Immediate intervention is needed to restore circulation.
D. A dressing change for a diabetic ulcer is important for wound healing and infection prevention, but it does not take priority over a potential loss of circulation.

A. A client who reports night sweats and fever for the last week B. A client who has compound fractures of the tibia and humerus C. A client who reports severe vomiting and diarrhea D. A client who has soot markings around each naris following a house fire

Correct Answer is D

Explanation

- A: Night sweats and fever could indicate an infection or a chronic condition, which, while important, may not require immediate attention compared to life-threatening conditions.
- B: Compound fractures are serious and require medical attention, but they are not immediately life-threatening if the patient is stable.
- C: Severe vomiting and diarrhea can lead to dehydration and electrolyte imbalance, which are concerning but can be managed with prompt treatment and do not typically pose an immediate threat to life.
- D: Soot markings around the naris indicate possible inhalation injury from a fire, which is a critical condition that can rapidly worsen and lead to airway compromise, making it the highest priority for immediate assessment and intervention.

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A nurse is delegating care for a group of clients. Which of the following clients should the nurse assign to the LPN?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse on a med-surge unit is caring for four clients. The nurse should recognize that which of the following clients is the priority?

Correct Answer is C

Explanation

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Correct Answer is D

Explanation

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