A registered nurse (RN) and an experienced licensed practical nurse (LPN) are caring for a group of clients. Which of the following tasks should the RN delegate to the LPN? SELECT ALL THAT APPLY

Initiate a plan of care for a client who is postoperative from an appendectomy.

Administer a tap-water enema to a client who is preoperative.

Provide discharge instructions to a confused client's spouse.

Catheterize a client who has not voided in 8 hours.

Obtain vital signs from a client who is 6 hours postoperative.

Answer and Explanation

Correct Answer : B,D,E

Choice A reason: Initiating a plan of care for a client who is postoperative from an appendectomy is not a task that the RN should delegate to the LPN, as it requires nursing judgment, critical thinking, and assessment skills that are beyond the scope of practice of the LPN. The RN is responsible for developing, implementing, and evaluating the plan of care for each client based on their individual needs, preferences, and goals. The RN can delegate some aspects of the plan of care to the LPN, such as performing routine tasks or monitoring the client's status, but the RN must supervise and evaluate the LPN's performance.

Choice B reason: Administering a tap-water enema to a client who is preoperative is a task that the RN can delegate to the LPN, as it is a standardized procedure that does not require nursing judgment or assessment. The LPN has the knowledge and skills to perform this task safely and effectively, following the established policies and protocols of the facility. The RN should provide clear instructions and expectations to the LPN, such as the type, amount, and temperature of the solution, the position and comfort of the client, and the signs and symptoms to report. The RN should also verify that the LPN has completed the task and documented the outcome.

Choice C reason: Providing discharge instructions to a confused client's spouse is not a task that the RN should delegate to the LPN, as it involves teaching, counseling, and evaluating the client's and family's understanding and readiness for discharge. These are complex activities that require nursing judgment, communication skills, and evaluation skills that are beyond the scope of practice of the LPN. The RN is responsible for ensuring that the client and family receive adequate information and education about the client's condition, treatment, medications, follow-up care, and community resources. The RN can delegate some aspects of discharge planning to the LPN, such as collecting data or providing reinforcement of teaching, but the RN must supervise and evaluate the LPN's performance.

Choice D reason: Catheterizing a client who has not voided in 8 hours is a task that the RN can delegate to the LPN, as it is a standardized procedure that does not require nursing judgment or assessment. The LPN has the knowledge and skills to perform this task safely and effectively, following the established policies and protocols of the facility. The RN should provide clear instructions and expectations to the LPN, such as the type and size of the catheter, the sterile technique, and the urine output measurement. The RN should also verify that the LPN has completed the task and documented the outcome.

Choice E reason: Obtaining vital signs from a client who is 6 hours postoperative is a task that the RN can delegate to the LPN, as it is a routine task that does not require nursing judgment or assessment. The LPN has the knowledge and skills to perform this task safely and effectively, using appropriate equipment and techniques. The RN should provide clear instructions and expectations to the LPN, such as the frequency and parameters of vital signs monitoring. The RN should also verify that the LPN has completed the task and documented the outcome.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is C

Explanation

Choice A reason: Gradual onset of several hours is not a manifestation of a hemorrhagic stroke. A hemorrhagic stroke occurs when a blood vessel in the brain bursts, causing bleeding into the surrounding tissue. This usually happens suddenly and without warning, and can cause rapid deterioration of the client's condition.

Choice B reason: Maintains consciousness is not a manifestation of a hemorrhagic stroke. A hemorrhagic stroke can cause increased intracranial pressure, which can compress the brain and impair its function. This can lead to loss of consciousness, coma, or death.

Choice C reason: Sudden severe headache is a manifestation of a hemorrhagic stroke. A hemorrhagic stroke can cause intense pain in the head, neck, or face, due to the pressure and irritation of the bleeding. The headache may be described as "the worst headache of my life" or "thunderclap headache".

Choice D reason: History of neurologic deficits lasting less than 1 hr. is not a manifestation of a hemorrhagic stroke. This is a characteristic of a transient ischemic attack (TIA), which is also known as a mini-stroke. A TIA occurs when a blood clot temporarily blocks an artery in the brain, causing temporary symptoms such as weakness, numbness, vision loss, or speech difficulty. A TIA does not cause permanent damage to the brain, but it is a warning sign of a possible future stroke.

A. Scheduling energy-intensive activities at the time of day when the client has higher energy levels. B. Scheduling all activities within a small block of time to allow the client a longer, uninterrupted rest period. C. Scheduling toilet breaks before and after any other planned activity. D. Scheduling the client's hygiene activities and limiting visitors.

Correct Answer is A

Explanation

Choice A reason: Scheduling energy-intensive activities at the time of day when the client has higher energy levels is the best activity plan for conserving the client's energy without compromising physical or mental health, as it allows the client to perform the tasks that require more effort and endurance when they feel more alert and capable. This can help the client to avoid fatigue, frustration, and injury, and to achieve their goals more effectively. The nurse should assess the client's individual preferences and patterns of energy fluctuation, and help them to prioritize and plan their activities accordingly.

Choice B reason: Scheduling all activities within a small block of time to allow the client a longer, uninterrupted rest period is not a good activity plan for conserving the client's energy without compromising physical or mental health, as it may cause the client to overexert themselves and deplete their energy reserves. This can lead to exhaustion, pain, and stress, and impair the client's recovery and quality of life. The nurse should advise the client to balance their activities with adequate rest periods throughout the day and to avoid doing too much or too little at once.

Choice C reason: Scheduling toilet breaks before and after any other planned activity is not a good activity plan for conserving the client's energy without compromising physical or mental health, as it may not be realistic or feasible for some clients. Some clients may have urinary or bowel problems that require them to use the toilet more frequently or urgently, such as incontinence, infection, or constipation. Forcing them to follow a rigid schedule may cause them discomfort, embarrassment, or complications. The nurse should assess the client's elimination needs and habits, and help them to manage their toileting needs in a comfortable and convenient way.

Choice D reason: Scheduling the client's hygiene activities and limiting visitors is not a good activity plan for conserving the client's energy without compromising physical or mental health, as it may neglect the client's social and emotional needs. Hygiene activities are important for maintaining the client's physical health and well-being, but they can also be tiring and challenging for some clients. Limiting visitors may reduce the noise and stimulation in the environment, but it can also isolate the client from their family and friends who can provide support and companionship. The nurse should assist the client with their hygiene needs as needed, and encourage them to interact with their visitors as tolerated.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A registered nurse (RN) and an experienced licensed practical nurse (LPN) are caring for a group of clients. Which of the following tasks should the RN delegate to the LPN? SELECT ALL THAT APPLY

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has had a hemorrhagic stroke following a ruptured cerebral aneurysm. Which of the following manifestations should the nurse expect?

Correct Answer is C

Explanation

A nurse is developing an activity plan for a client. The nurse should recognize that which activity plan would best conserve the client's energy without compromising physical or mental health.

Correct Answer is A

Explanation

A client is receiving rehabilitation for paralysis following a spinal cord injury and is diagnosed with reflex incontinence. Which of the following is the highest priority intervention the nurse should include in the plan of care?

The nurse is preparing for an initial home care visit for a client with diabetes. Which action by the nurse is appropriate? SELECT ALL THAT APPLY

The hospital's Emergency Operations Committee is working on their disaster plan. In which components should nurses be included? SELECT ALL THAT APPLY

A nurse is delegating tasks to assistive personnel. Which of the following should the nurse consider when using one of the five rights of delegation?

A nurse enters the room of a client and discovers the client with new right-sided weakness and slurred speech. Which of the following actions should the nurse take?

A nurse is assessing a client who reports a severe headache and stiff neck. The nurse's assessment reveals positive Kernig's and Brudzinski's signs. Which of the following actions should the nurse perform first?

A nurse is teaching a client who has a new prescription for sumatriptan (Imitrex) tablets to treat migraine headaches. Which of the following instructions should the nurse include?

A nurse is caring for a client with a myocardial infarction. The client questions the need for cardiac rehabilitation since "my heart is already damaged." Which of the following is the appropriate nursing response?