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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
a. In emergency situations where obtaining informed consent is not feasible due to the client's unconscious state and immediate need for surgery to preserve life or prevent further harm, the client may be transported to the operating room without obtaining formal consent. This action is based on the principle of implied consent for emergent, life-saving interventions.
b. Delaying surgery to obtain informed consent could result in further harm to the client if immediate intervention is necessary to stabilize their condition.
c. Obtaining telephone consent from the facility administrator is not appropriate in this situation, as the client's immediate medical needs take precedence over administrative procedures.
d. Asking the anesthesiologist to sign the consent is not appropriate, as consent should ideally be obtained from the client or their legally authorized representative.
Correct Answer is A
Explanation
a. Instituting rounds every 2 hours during the day to offer toileting can help prevent falls by addressing residents' toileting needs and reducing the risk of falls associated with attempting to ambulate to the bathroom independently.
b. Keeping four side rails up on the beds at night may increase the risk of entrapment and should be avoided as a fall prevention strategy.
c. Applying restraints, such as vest restraints, is not recommended as a fall prevention measure and may increase agitation and risk of injury.
d. While providing assistance during ambulation is important, it is not necessary to accompany all residents older than 85 years of age. Ambulation assistance should be provided based on individual assessment of mobility and fall risk.
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