In what patient situations would a partial ongoing assessment be best performed?
On initial evaluation by the home health nurse.
Reassessing a client for pain after giving pain medication.
Checking skin assessment on a patient with a medical device in place.
Preparing the client for discharge.
The Correct Answer is B
Choice A rationale
On initial evaluation by the home health nurse, a comprehensive assessment is typically performed to gather baseline data. This initial assessment is thorough and includes a detailed history and physical examination to understand the patient’s overall health status. It is not a partial ongoing assessment, which is more focused and conducted after the initial comprehensive assessment to monitor specific issues or changes in the patient’s condition.
Choice B rationale
Reassessing a client for pain after giving pain medication is an example of a partial ongoing assessment. This type of assessment is focused on evaluating the effectiveness of an intervention, such as pain medication, and determining if further action is needed. It involves collecting specific data related to the patient’s pain levels and response to treatment, rather than a comprehensive evaluation of their overall health.
Choice C rationale
Checking skin assessment on a patient with a medical device in place is also an example of a partial ongoing assessment. This focused assessment is conducted to monitor the condition of the skin around the medical device, looking for signs of pressure ulcers, infection, or other complications. It is not a comprehensive assessment but rather a targeted evaluation of a specific area of concern.
Choice D rationale
Preparing the client for discharge involves a comprehensive assessment to ensure that the patient is ready to leave the healthcare facility and can manage their care at home. This assessment includes evaluating the patient’s physical, psychological, and social needs, as well as their ability to perform activities of daily living. It is not a partial ongoing assessment, which is more focused and conducted during the course of care to monitor specific issues.
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Correct Answer is D
Explanation
Choice A rationale
Fatigue is a subjective symptom reported by the client. It is based on the client’s personal experience and cannot be objectively measured or observed by the nurse. Therefore, it is not considered objective data.
Choice B rationale
Dizziness is also a subjective symptom reported by the client. It reflects the client’s personal experience and cannot be directly observed or measured by the nurse. As such, it is not considered objective data.
Choice C rationale
Numbness is another subjective symptom reported by the client. It is based on the client’s personal sensation and cannot be objectively measured or observed by the nurse. Therefore, it is not considered objective data.
Choice D rationale
Physical examination results are objective data. They are obtained through direct observation, measurement, and assessment by the nurse. Examples of objective data include vital signs, physical examination findings, and laboratory results. These data are reproducible and can be verified by other healthcare professionals.
Correct Answer is C
Explanation
Choice A rationale
A 30-year-old male patient with an active GI bleed requiring multiple blood transfusions is not suitable for assignment to an LPN. This patient is unstable and requires close monitoring and frequent assessments, which are beyond the LPN’s scope of practice. The RN should manage this patient to ensure proper care and timely interventions.
Choice B rationale
A 55-year-old male patient who is post-surgery and ready for discharge, requiring discharge instructions, is also not suitable for assignment to an LPN. Discharge instructions involve comprehensive education and assessment of the patient’s understanding, which are responsibilities of the RN. The RN must ensure the patient comprehends the instructions and can safely manage their care at home.
Choice C rationale
A 40-year-old diabetic patient requiring re-teaching on insulin administration is the best choice for assignment to an LPN. This patient is stable and the task of re-teaching insulin administration falls within the LPN’s scope of practice. The LPN can effectively provide education and ensure the patient understands how to administer insulin correctly.
Choice D rationale
A newly admitted patient is not suitable for assignment to an LPN. New admissions require comprehensive assessments and care planning, which are responsibilities of the RN. The RN must evaluate the patient’s condition, develop a care plan, and initiate appropriate interventions.
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