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.
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Related Questions
Correct Answer is C
Explanation
A. "The vital signs are stable." This statement belongs in the Assessment (A) step, as it provides information about the client’s current clinical condition.
B. "The client has a history of high blood pressure." This statement belongs in the Background (B) step, providing relevant medical history.
C. "The client is disoriented. Pupils are slow to respond to light." The S (Situation) step involves stating the immediate problem or reason for the communication. Describing the client's disorientation and pupil response directly addresses the current issue that prompted the call.
D. "The client should be seen by a neurologist." This statement belongs in the Recommendation (R) step, suggesting the next course of action.
Correct Answer is C
Explanation
A. Verbal communication is often an accurate reflection of what the client really feels: Verbal communication may not always accurately reflect true feelings, especially if the client is trying to mask their emotions.
B. Nonverbal communication accurately reflects what the client is saying: Nonverbal communication can sometimes contradict what the client is verbally expressing, providing additional context or revealing hidden emotions.
C. An example of nonverbal communication body posture: Body posture is a significant form of nonverbal communication, providing insights into a client’s comfort, confidence, and emotional state.
D. Facial expressions are an example of verbal communication: Facial expressions are a form of nonverbal communication, conveying emotions and reactions without words.
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