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.
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Related Questions
Correct Answer is B
Explanation
The most concerning finding in the assessment of a client's right leg after a femoropopliteal bypass graft would be if the client's pedal pulse in the right foot is not palpable. This could indicate a problem with blood flow to the limb.
The other options are also concerning and should be reported to the healthcare provider.
a) A cooler footmay indicate decreased blood flow to the limb.
c) A capillary refill time of 5 secondsmay also indicate decreased blood flow.
d) A pain level of 8 on a scale from 0 to 10should also be reported and addressed.
Correct Answer is B
Explanation
b. Perform passive range-of-motion exercises.
During a vaso-occlusive crisis in sickle-cell disease, blood flow to certain areas of the body may be restricted, leading to pain and tissue damage. Passive range-of-motion exercises can help promote blood circulation and prevent joint stiffness and further complications. These exercises involve gently moving the child's joints through their full range of motion without active participation from the child.
Explanation for the other options:
a. Limit fluid intake during the evening: Fluid intake is important in sickle-cell disease to prevent dehydration and maintain adequate blood flow. Restricting fluid intake during a vaso-occlusive crisis can further contribute to dehydration and may worsen the crisis. It is important to encourage fluid intake unless otherwise instructed by the healthcare provider.
c. Apply cold compresses to painful areas: Cold compresses are not recommended during a vaso-occlusive crisis in sickle-cell disease. Cold temperatures can cause vasoconstriction and further worsen the blood flow to affected areas, leading to increased pain and tissue damage. Warm compresses or warm packs may be used to promote vasodilation and provide pain relief.
d. Provide a low-protein diet: A low-protein diet is not specifically indicated in the plan of care for a vaso- occlusive crisis in sickle-cell disease. Adequate protein intake is important for overall nutritional needs and tissue repair. The focus of nutritional management in sickle-cell disease is usually on a well-balanced diet that includes adequate hydration and appropriate nutrient intake.
In summary, performing passive range-of-motion exercises is an appropriate intervention to include in the
plan of care for a school-age child experiencing a vaso-occlusive crisis in sickle-cell disease.
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