A nurse on a medical surgical unit has received report on four clients. There is an LVN, RN, and UAP working. Which of the following clients would best to assign to the RN?
Reinforcing teaching with a patient who is learning to walk with a quad cane
A new admission to the unit complaining of chest pain
Inserting an NGT for a client who is unable to eat
Calculating intake and output for the unit
The Correct Answer is B
A. Reinforcing teaching with a patient who is learning to walk with a quad cane: Reinforcing teaching can be done by an LVN, as it involves stable, predictable outcomes.
B. A new admission to the unit complaining of chest pain: A new admission with chest pain requires a comprehensive assessment and potential critical thinking and intervention, which are within the scope of an RN.
C. Inserting an NGT for a client who is unable to eat: Inserting an NGT can be done by an RN or LVN, but it does not require the comprehensive assessment and critical thinking that managing a new admission with chest pain does.
D. Calculating intake and output for the unit: Calculating intake and output is a task that can be delegated to a UAP.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Assessment: The Assessment section includes the nurse's findings and interpretations of the client's current condition. Information specific to sleep apnea would more likely be part of the client's history and not a direct assessment finding at this time.
B. Background: The Background section includes relevant background information that could impact the client’s current situation. This would be the appropriate section to include the client's history of sleep apnea.
C. Situation: The Situation section focuses on the current issue or reason for the communication. While it should be concise, it does not include detailed past medical history unless directly relevant to the current situation.
D. Recommendation: The Recommendation section is where the nurse suggests the next steps or interventions needed. Information about sleep apnea is not a recommendation but part of the client's background.
Correct Answer is C
Explanation
A. Vomiting: Vomiting is objective data because it can be observed and measured by the nurse.
B. Auscultation of heart murmur: This is objective data obtained through physical examination techniques.
C. Client's complaint of nausea: Subjective data is information reported by the client about their experience, feelings, or symptoms, which cannot be directly observed by others.
D. Blood pressure reading: This is objective data obtained through measurement.
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