A nurse is reviewing his client care assignments after receiving change-of-shift report. The nurse should notify the charge nurse that which of the following tasks should be reassigned to an RN?
Inserting an indwelling urinary catheter
Administering heparin subcutaneously
Suctioning a client's new tracheostomy
Classifying a pressure ulcer
The Correct Answer is C
A. Inserting an indwelling urinary catheter can be performed by licensed practical nurses (LPNs) under the supervision of an RN, so this task does not need to be reassigned.
B. Administering heparin subcutaneously is a task that can be performed by LPNs, so it does not require reassignment to an RN.
C. Suctioning a client's new tracheostomy is a more complex procedure that requires advanced skills and assessment, making it appropriate for an RN rather than an LPN.
D. Classifying a pressure ulcer is a task that can be done by both RNs and LPNs, so it does not need to be reassigned.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Reporting the concern to the charge nurse is the appropriate action, as it ensures that the issue is addressed through proper channels. The charge nurse can investigate and determine if further action is needed, such as reviewing the medication administration process.
B. Questioning the nurse directly could lead to confrontations and is not the correct procedure for handling potential discrepancies in medication administration.
C. Notifying the pharmacy is unnecessary at this point because the issue concerns administration rather than medication supply or errors with the prescription.
D. While documenting the client’s report is important, simply documenting the client’s claim without notifying the charge nurse does not fully address the concern.
Correct Answer is B
Explanation
A. Seclusion is a highly restrictive intervention and is not the first action for managing agitation in dementia clients.
B. Engaging the client in a repetitive activity as a distraction is the least restrictive intervention and can help calm the client by redirecting their attention. Non-pharmacological and less restrictive approaches are preferred as initial responses to manage agitation in dementia clients.
C. Administering PRN haloperidol IM is a pharmacological intervention and should be reserved for situations where less restrictive measures have failed.
D. Applying wrist restraints is a restrictive intervention that can increase agitation and is not appropriate as a first-line approach.
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