An RN is making nursing staff assignments for his team consisting of himself, two licensed practical nurses (LPNs), and an assistive personnel (AP). Which of the following clients should he assume responsibility for?

The client who is actively dying and requires IV pain medication

The client who is 3 days postoperative and requires a dressing change

The client who requires frequent ambulation

The client who is in protective isolation

Answer and Explanation

The Correct Answer is A

A.   This client needs IV pain medication, which requires advanced skills and knowledge to manage and administer safely. This situation involves complex and sensitive care, including pain management and end-of-life issues. RNs are typically responsible for administering IV medications, especially in critical or end-of-life situations.
B.   A client who is 3 days postoperative and needs a dressing change generally requires a level of care that may be suitable for LPNs. LPNs are trained to perform dressing changes and manage postoperative wounds. However, if there are complications or concerns about the wound or the client’s condition, the RN should oversee or handle the situation.
C.   Frequent ambulation can be managed by assistive personnel (AP) under the supervision of the RN. This task typically involves supporting and assisting the client with walking, which is within the scope of AP duties. LPNs can also assist with ambulation, but it is generally a task appropriate for APs when performed as part of routine care.
D.   A client in protective isolation requires careful attention to infection control practices to protect them from infections. While the RN is responsible for ensuring adherence to isolation protocols and assessing the client’s needs, the day-to-day care tasks might be managed by LPNs and APs, provided they are trained in infection control procedures.

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Correct Answer is ["A","B","D"]

Explanation

A. This is subjective data. The description of pain as "dull" and "aching" is based on the client's personal experience and cannot be measured directly by the nurse. Pain is a subjective symptom because it varies from person to person and is reported by the patient.
B. This is subjective data. Nausea is a feeling or sensation reported by the client and is based on their personal experience. The nurse relies on the client's report to assess this symptom, as it cannot be directly observed or measured.
C. This is objective data. The temperature reading is a measurable, quantifiable fact that can be directly observed and recorded by the nurse using a thermometer. It provides concrete evidence of the client's condition.
D. This is subjective data. Itchiness is a sensation reported by the client and is based on their personal experience. The nurse cannot measure itchiness directly; they rely on the client’s description to understand the symptom.
E. This is objective data. The presence of a vesicular rash is an observable finding that the nurse can see and document. It is a physical characteristic that can be directly assessed and recorded.

A. A school-age child who has diabetes mellitus and requires blood glucose monitoring B. An adolescent who was admitted to the unit in sickle cell crisis and is ready for discharge instructions C. A toddler who has both arms in casts and needs to be fed his breakfast D. An infant who has pertussis and is receiving oxygen via nasal cannula

Correct Answer is D

Explanation

A. Monitoring blood glucose is crucial for managing diabetes, as it directly affects the child's blood sugar levels and overall well-being. However, if the child’s blood glucose levels are stable and there are no immediate concerns or symptoms, this task, while important, may not be as urgent as assessing more critically ill clients.
B. While discharge instructions are important for ensuring proper care after leaving the hospital, this task generally does not require immediate attention compared to assessing a client with more acute or urgent needs. The adolescent is ready for discharge, indicating their condition is stable enough to prepare for leaving the unit.
C. Feeding a toddler who has both arms in casts is important for ensuring that the child is well-nourished and comfortable. However, this task can usually be managed by assistive personnel or done at a scheduled time without immediate urgency compared to more critical assessments.
D. An infant with pertussis (whooping cough) receiving oxygen via nasal cannula is in a potentially critical situation. Pertussis can cause significant respiratory distress, and the need for oxygen indicates the
infant’s respiratory function is compromised. Assessing this infant first is crucial to ensure that the oxygen therapy is effective and to monitor for any signs of deterioration in respiratory status.

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An RN is making nursing staff assignments for his team consisting of himself, two licensed practical nurses (LPNs), and an assistive personnel (AP). Which of the following clients should he assume responsibility for?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is documenting assessment findings on a client. Which of the following entries should the nurse identify as subjective data? (Select All that Apply.)

Correct Answer is ["A","B","D"]

Explanation

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Correct Answer is D

Explanation

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