A nurse on a medical-surgical unit is caring for a group of clients with the assistance of a licensed practical nurse (LPN) and an assistive personnel. Which of the following tasks should the nurse assign to the LPN?
Accompanying a client who just had a wound debridement to physical therapy
Providing postmortem care for a client who has just died
Obtaining a urine specimen from an older adult client
Reinforcing dietary teaching with a client who has heart disease
The Correct Answer is D
Choice A reason: Accompanying a client who just had a wound debridement to physical therapy is not a task that the nurse should assign to the LPN, as it requires the nurse to monitor the client's vital signs, wound status, and pain level. The nurse should accompany the client and delegate other tasks to the LPN or the assistive personnel.
Choice B reason: Providing postmortem care for a client who has just died is not a task that the nurse should assign to the LPN, as it requires the nurse to verify the death, notify the provider and the family, and document the care. The nurse should provide postmortem care and delegate other tasks to the LPN or the assistive personnel.
Choice C reason: Obtaining a urine specimen from an older adult client is not a task that the nurse should assign to the LPN, as it is a basic skill that the assistive personnel can perform. The nurse should assign this task to the assistive personnel and supervise their work.
Choice D reason: Reinforcing dietary teaching with a client who has heart disease is a task that the nurse should assign to the LPN, as it is within the LPN's scope of practice to reinforce the teaching that the nurse has initiated. The nurse should provide the initial teaching and evaluate the client's learning.
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Correct Answer is D
Explanation
Choice A reason: This is not the correct choice because low pain tolerance is not the most urgent issue to address. The client may experience some pain and discomfort after the surgery, but this can be managed with medication and non-pharmacological interventions. The nurse should educate the client on how to use pain scales, request pain relief, and apply ice packs or heat pads as needed.
Choice B reason: This is not the correct choice because decreased self-esteem is not the most urgent issue to address. The client may have some negative feelings about their appearance or abilities after the surgery, but this can be improved with counseling and support groups. The nurse should encourage the client to express their emotions, focus on their strengths, and seek professional help if necessary.
Choice C reason: This is not the correct choice because limited social support is not the most urgent issue to address. The client may have difficulty coping with the recovery process and the lifestyle changes required after the surgery, but this can be alleviated with community resources and referrals. The nurse should assess the client's social network, provide information on local agencies and organizations, and arrange for home health care or visiting nurses if needed.
Choice D reason: This is the correct choice because inadequate food supply is the most urgent issue to address. The client needs to have access to nutritious and balanced meals to promote healing and prevent complications after the surgery. The nurse should evaluate the client's food security, provide food vouchers or coupons, and connect the client with food banks or meal delivery services.
Correct Answer is B
Explanation
Choice A reason: Diminished hand-to-mouth coordination is not a finding that requires a referral to speech-language pathology, as it is related to the motor function of the upper extremities. The nurse should refer the client to physical therapy or occupational therapy for this issue.
Choice B reason: Impaired voluntary cough is a finding that requires a referral to speech-language pathology, as it indicates a possible dysfunction of the swallowing mechanism or the vocal cords. The nurse should refer the client to speech-language pathology for a swallowing evaluation and intervention.
Choice C reason: Altered level of consciousness is not a finding that requires a referral to speech-language pathology, as it is related to the neurological function of the brain. The nurse should monitor the client's Glasgow Coma Scale score and report any changes to the provider.
Choice D reason: Unilateral ptosis is not a finding that requires a referral to speech-language pathology, as it is related to the cranial nerve function of the eye. The nurse should assess the client's pupillary response and eye movements and report any abnormalities to the provider.
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