A nurse is reviewing client care assignments prior to the beginning of a shift. Which of the following client assignments should the nurse identify as being outside the scope of practice for an LPN?
A client who has a new onset of chest pain
A client who has a tracheostomy
A client who is receiving enteral feedings
A client who has urinary retention
The Correct Answer is A
A. A client who has a new onset of chest pain requires immediate assessment and intervention by an RN or healthcare provider with appropriate training and licensure due to the potential seriousness of the condition. Assessing and managing chest pain typically involves performing an ECG, administering medications, and coordinating further diagnostic tests or interventions, which are typically within the scope of practice of an RN or higher.
B. A client who has a tracheostomy may require routine tracheostomy care and suctioning, which are within the scope of practice of an LPN under the supervision of an RN or healthcare provider.
C. A client who is receiving enteral feedings may require monitoring of feeding tube placement, administration of enteral feedings, and assessment for complications related to enteral nutrition, which are within the scope of practice of an LPN.
D. A client who has urinary retention may require urinary catheterization or bladder scan assessment, which are within the scope of practice of an LPN under the supervision of an RN or healthcare provider.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Platelets within the normal range indicate appropriate clotting function and are not concerning in this scenario.
B. Red blood cell (RBC) count within the normal range suggests normal oxygen-carrying capacity and is not directly related to the client's symptoms.
C. Hemoglobin (Hgb) level within the normal range indicates adequate oxygen-carrying capacity and is not directly related to the client's symptoms.
D. An international normalized ratio (INR) of 5.2 is significantly elevated and indicates that the client's blood is not clotting properly. This could be a result of excessive anticoagulation from heparin therapy, which may lead to bleeding complications such as bloody stools. Therefore, the nurse should report this finding to the provider for further evaluation and possible adjustment of the anticoagulant therapy.
Correct Answer is D
Explanation
A. A warm extremity is not typically associated with compartment syndrome. Compartment syndrome may present with coolness due to compromised circulation.
B. Moderate pain on the ankle may be present in compartment syndrome due to increased pressure within the compartment, but it is not a specific manifestation.
C. Blanch time of 2 seconds in the toenail beds indicates normal capillary refill, which is not consistent with compartment syndrome. In compartment syndrome, capillary refill may be delayed.
D. Palpation of a weak or absent dorsalis pedis pulse is a concerning finding indicative of compromised circulation, a hallmark sign of compartment syndrome.
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