A nurse is delegating care for a group of clients. Which of the following clients should the nurse assign to a licensed practical nurse?
A newly admitted client who has diabetes mellitus and requires initial teaching on self- administration of insulin
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.
The Correct Answer is B
- A: This client requires initial teaching, which is typically the responsibility of a registered nurse due to the educational aspect and the need to assess the client's understanding.
- B: Administering an enema is a task that falls within the scope of practice for a licensed practical nurse and does not require the advanced assessment skills of a registered nurse.
- C: Developing an initial plan of care involves comprehensive assessment and critical thinking, which are responsibilities of a registered nurse.
- D: A client transferring from the CCU after a myocardial infarction would require close monitoring and assessment, which are beyond the scope of practice for a licensed practical nurse.
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Related Questions
Correct Answer is B
Explanation
A. A client who has peripheral vascular disease and has an absent pedal pulse in the right foot is not the highest priority because this is a chronic condition that does not pose an
immediate threat to the client's health. The nurse should monitor the client's circulation, provide education on foot care, and encourage smoking cessation if applicable.
B. This client is at risk for urinary retention, which can lead to bladder distension,
infection, and renal damage. The nurse should assess the client's bladder, perform a
bladder scan, and notify the provider if indicated. This is the most urgent situation that requires immediate intervention.
C. A client who is newly diagnosed with pancreatic cancer and is scheduled to begin IV chemotherapy is not the highest priority because this is a planned procedure that does not require immediate action. The nurse should prepare the client for chemotherapy, provide emotional support, and teach the client about potential side effects and complications.
D. A client who has methicillin-resistant Staphylococcus aureus (MRSA) and has an
axillary temperature of 38° C (101° F) is not the highest priority because this is a sign of infection that can be managed with antibiotics and infection control measures. The nurse should administer the prescribed antibiotics, monitor the client's vital signs, and
implement contact precautions.
Correct Answer is D
Explanation
A. Dismissing the client's concerns and suggesting pain medication without addressing the client's worries isn't an empathetic or helpful response.
B. Asking why the client didn't discuss concerns with the provider might make the client feel guilty or judged for their decision.
C. Pressuring the client by suggesting avoiding future pain and disability isn't respectful of the client's current concerns and decision-making.
D. Acknowledging the client's worries and affirming their ability to change their mind is an appropriate and supportive response.
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