After receiving a change of shift report for clients on a medical surgical unit, which activity should the nurse delegate to the practical nurse (PN)?
Evaluate and update plans of care for clients.
Verify the readiness of clients for discharge.
Insert urinary catheters for uncomplicated clients.
Receive a postoperative client and conduct the assessment.
The Correct Answer is C
Delegation involves assigning tasks to individuals who have the appropriate skills and competence to perform them safely and effectively. Inserting urinary catheters for uncomplicated clients is a task that can be delegated to a practical nurse. It is a common procedure within the scope of practice for a practical nurse, and it does not require the level of assessment and critical thinking involved in evaluating and updating plans of care or receiving a postoperative client and conducting an assessment.
Verifying the readiness of clients for discharge typically involves comprehensive assessments, coordination with other healthcare professionals, and decision-making regarding the appropriateness of discharge. This task is generally performed by registered nurses (RNs) or other members of the healthcare team with advanced training.
Evaluating and updating plans of care for clients is a responsibility that falls within the scope of practice of registered nurses. It requires a higher level of assessment, clinical judgment, and decision-making, which are typically beyond the scope of practice of a practical nurse.
Receiving a postoperative client and conducting the assessment involves comprehensive assessment skills and critical thinking, which are typically within the scope of practice of a registered nurse or an advanced practice nurse.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. A 12-year-old reporting neck, arm, and lower back discomfort:
- This child is reporting discomfort, which is concerning, but it doesn't indicate an immediate life-threatening condition. However, a thorough assessment is needed to rule out any serious injuries, especially to the spine.
B. An 8-year-old with a full leg air splint for a possible broken tibia:
- While a possible broken tibia requires attention, it is not as immediately critical as symptoms such as projectile vomiting. Splinting can help stabilize the limb, but it is not an emergency that requires immediate attention compared to potential neurological issues.
C. A 6-year-old with multiple superficial lacerations of all extremities:
- Superficial lacerations, although they require care, are generally not immediately life-threatening. The child needs appropriate wound care and assessment for any deeper injuries, but this can be addressed in a timely manner without immediate urgency.
D. An 11-year-old with a headache, nausea, and projectile vomiting:
- This is the most concerning presentation among the options. Headache, nausea, and projectile vomiting could be indicative of a severe head injury, and these neurological symptoms require urgent evaluation to assess for conditions such as a concussion, intracranial bleed, or increased intracranial pressure.
Correct Answer is ["B","C","D","E","H"]
Explanation
- Capillary refill: This is a quick and simple way to assess the adequacy of peripheral perfusion and can help identify signs of dehydration.
- Skin turgor: Assessing the skin turgor, or the elasticity of the skin, is another useful indicator of dehydration.
- Heart rate: Tachycardia can be a sign of dehydration, so monitoring the heart rate is an important component of the assessment.
- Blood pressure: Blood pressure can be affected by dehydration, so monitoring it is important in determining the severity of dehydration and in guiding appropriate interventions.
- Temperature: Fever is a potential cause of dehydration, so monitoring the temperature is an important part of the assessment.
- Skin color of hands and feet: Checking the color of the skin on the hands and feet can help identify signs of poor perfusion and dehydration.
Assessing the level of consciousness, pupil size and reactiveness, and respiratory rate are important aspects of the neurological and respiratory assessments but are not specific to the assessment of dehydration.
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