A nurse on a medical-surgical unit has received a report on four clients. Which of the following clients should the nurse assign to the RN?
Feeding a stroke client who has difficulty in swallowing.
Completing a sterile dressing change to a pressure ulcer.
Reapplying a condom catheter for a client with urinary incontinence.
Reinforcing teaching with a client who is learning how to administer insulin.
The Correct Answer is B
Choice A rationale
Feeding a stroke client who has difficulty in swallowing is a task that requires careful attention to prevent aspiration and choking. While this task is important, it can be delegated to a trained nursing assistant or a licensed practical nurse (LPN) under the supervision of an RN. The RN should focus on tasks that require higher levels of clinical judgment and expertise.
Choice B rationale
Completing a sterile dressing change to a pressure ulcer is a task that requires the expertise and clinical judgment of an RN. Sterile dressing changes involve maintaining a sterile field, assessing the wound, and applying appropriate dressings. This task is critical for preventing infection and promoting wound healing, making it appropriate for the RN to perform.
Choice C rationale
Reapplying a condom catheter for a client with urinary incontinence is a routine procedure that can be delegated to a trained nursing assistant or an LPN. This task does not require the advanced clinical skills and judgment of an RN, allowing the RN to focus on more complex and critical tasks.
Choice D rationale
Reinforcing teaching with a client who is learning how to administer insulin is an important task, but it can be delegated to an LPN under the supervision of an RN. The RN should prioritize tasks that require higher levels of clinical expertise and judgment, such as sterile dressing changes and complex assessments.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
On initial evaluation by the home health nurse, a comprehensive assessment is typically performed to gather baseline data. This initial assessment is thorough and includes a detailed history and physical examination to understand the patient’s overall health status. It is not a partial ongoing assessment, which is more focused and conducted after the initial comprehensive assessment to monitor specific issues or changes in the patient’s condition.
Choice B rationale
Reassessing a client for pain after giving pain medication is an example of a partial ongoing assessment. This type of assessment is focused on evaluating the effectiveness of an intervention, such as pain medication, and determining if further action is needed. It involves collecting specific data related to the patient’s pain levels and response to treatment, rather than a comprehensive evaluation of their overall health.
Choice C rationale
Checking skin assessment on a patient with a medical device in place is also an example of a partial ongoing assessment. This focused assessment is conducted to monitor the condition of the skin around the medical device, looking for signs of pressure ulcers, infection, or other complications. It is not a comprehensive assessment but rather a targeted evaluation of a specific area of concern.
Choice D rationale
Preparing the client for discharge involves a comprehensive assessment to ensure that the patient is ready to leave the healthcare facility and can manage their care at home. This assessment includes evaluating the patient’s physical, psychological, and social needs, as well as their ability to perform activities of daily living. It is not a partial ongoing assessment, which is more focused and conducted during the course of care to monitor specific issues.
Correct Answer is B
Explanation
Choice A rationale
Ensuring the client can independently manage their care is important, but it does not directly address potential barriers that could affect adherence to the discharge plan. Identifying barriers is crucial to ensure the client can follow through with the plan safely and effectively.
Choice B rationale
Identifying potential barriers to adherence is essential for client safety during the discharge process. This includes assessing the client’s understanding of their care plan, their ability to access medications, and any social or financial obstacles that may hinder their adherence. By addressing these barriers, the nurse can help ensure the client follows the discharge plan and reduces the risk of complications or readmissions.
Choice C rationale
Avoiding discussion of dietary restrictions is incorrect because dietary restrictions are often a critical component of a client’s care plan. Discussing and ensuring the client understands these restrictions is vital for their safety and health management post-discharge.
Choice D rationale
Providing information quickly to expedite discharge is not a safe practice. It is important to ensure the client fully understands their discharge instructions, which requires taking the time to explain and confirm comprehension. Rushing through this process can lead to misunderstandings and potential harm.
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