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

Answer and Explanation

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.

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Correct Answer is D

Explanation

A. Contacting the provider for instructions could delay immediate resuscitative efforts, which are required in the absence of a DNR order.
B. Consulting with the client’s family may not be effective in an emergency, as the living will is a legal document, and family members cannot override it without a DNR order.
C. Complying with the living will and letting the client expire naturally would be inappropriate without a formal DNR order in place.
D. Calling a code is the correct action because, legally, resuscitative efforts must be initiated in the absence of a written DNR order from the provider, despite the existence of a living will.

A. Record in the nurse's notes that an incident report was filed. B. Give the family a copy of the incident report. C. Document the facts about the incident in the medical record. D. Place a copy of the incident report in the medical record.

Correct Answer is C

Explanation

A. While the nurse's notes may include observations about the client's condition, recording that an incident report was filed does not provide pertinent details regarding the client's care and is not appropriate.
B. Incident reports are confidential documents and should not be shared with the client's family, so providing a copy of the report is inappropriate.
C. Documenting the facts about the incident in the medical record is essential to provide a complete account of the client's care and any resulting changes or observations. This documentation is important for continuity of care and legal purposes.
D. Incident reports should not be placed in the medical record, as they are separate documents intended for internal review and quality assurance purposes.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is D

Explanation

A nurse in a long-term care facility is caring for a client who received a superficial burn from a heating pad that malfunctioned. After completing an incident report, which of the following actions should the nurse take?

Correct Answer is C

Explanation

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