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
The nurse should identify that caring for a client who has a new onset of chest pain is outside the scope of practice for an LPN. This is a complex and potentially life-threatening situation that requires the assessment and intervention of a registered nurse (RN) or other advanced practice provider.
b) Caring for a client who has a tracheostomy is within the scope of practice for an LPN.
c) Caring for a client who is receiving enteral feedings is within the scope of practice for an LPN.
d) Caring for a client who has urinary retention is within the scope of practice for an LPN.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B"]
Explanation
Answer: B
Rationale:
A) Use written signs to assist the client with locating the bathroom: While written signs may be helpful in the earlier stages of Alzheimer's disease, as the disease progresses, clients may lose the ability to read and comprehend written language. Visual cues, such as pictures or color-coded indicators, tend to be more effective in helping clients navigate their environment.
B) Limit the number of choices for the client: Limiting choices reduces confusion and anxiety for clients with Alzheimer's disease. Providing too many options can overwhelm them, making decision-making difficult. Offering simple, clear choices helps to maintain a sense of autonomy while minimizing stress.
C) Provide a stimulating environment for the client: Although some stimulation can be beneficial, excessive stimulation can overwhelm a client with Alzheimer's disease, leading to agitation and confusion. It's important to create a calm, structured environment that promotes safety and reduces anxiety.
D) Use confrontation to manage the client’s behavior: Confrontation should be avoided when managing the behavior of clients with Alzheimer's disease. Confronting or challenging them can increase agitation and lead to further confusion. Instead, caregivers should use distraction, redirection, and a calm approach to manage difficult behaviors effectively.
Correct Answer is C
Explanation
When instructing a client on self-administration of nasal drops, the nurse should recommend the supine position. In the supine position, the client lies on their back with the head slightly elevated. This position allows for easy access to the nostrils and facilitates the proper instillation of the nasal drops.
The other options are not recommended for instillation of nasal drops for various reasons:
a) Sims position: Simsposition is a side-lying position with the upper leg flexed. This position is often used for rectal examinations or procedures and is not suitable for instilling nasal drops.
b) Prone position: Prone position refers to lying face down. It is not ideal for administering nasal drops as it
can obstruct proper access to the nostrils and make it difficult to instill the drops accurately.
d) Orthopneic position: Orthopneic position is a sitting position with the upper body supported by pillows. It is commonly used by individuals with respiratory distress to facilitate breathing. However, it is not specifically recommended for administering nasal drops as it may not provide optimal access to the nostrils for proper instillation.
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