It is most important to assign which client to a registered nurse rather than a practical nurse (PN)?
One hour after receiving hydromorphone prescribed for every 4 hours PRN use, a client reports severe pain.
Two hours after receiving morphine for acute pain, a client's vital signs are BP 112/60 mm Hg, pulse 88 beats/minute, and respirations 14 breaths/minute.
After ambulating, a postoperative client grimaces and reports incisional pain at a "9 on a ten-point scale".
The fentanyl transdermal patch for a client with chronic cancer pain needs to be replaced.
The Correct Answer is C
Choice A Reason: This client may need another dose of hydromorphone if the pain is not relieved by the previous one. A PN can administer this medication under the supervision of a RN and monitor the client's response.
Choice B Reason: This client's vital signs are within normal limits and indicate that the morphine is effective and not causing respiratory depression. A PN can assess and document the client's vital signs and pain level.
Choice C Reason: This is the correct answer because this client has acute and severe pain that may require immediate intervention and reassessment. An RN can evaluate the cause and severity of the pain, administer additional analgesics as prescribed, and implement nonpharmacological measures to relieve the pain.
Choice D Reason: This client has chronic and stable pain that is managed by a fentanyl patch. A PN can replace the patch according to the schedule and instructions provided by the RN.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A Reason:Notifying the prescriber is essential, but it is secondary to obtaining objective data. The nurse must first secure timely laboratory results to report concrete values. Immediate notification without current coagulation data delays informed decision-making about reversal, dosing changes, or additional interventions.
Choice B Reason: Monitoring for signs of bleeding is important but not the priority action for the nurse because it does not address the cause of the problem or prevent further harm. The nurse should monitor the client's vital signs, hemoglobin, hematocrit, and urine output, as well as check for any signs of bleeding, such as bruising, petechiae,
hematuria, hematemesis, melena, or epistaxis.
Choice C Reason: Completing an adverse occurrence report is important but not the priority action for the nurse because it does not provide immediate intervention or treatment for the client. The nurse should complete an
adverse occurrence report after notifying the healthcare provider and implementing appropriate actions. The report should include the details of the error, such as the time, dose, route, and name of the medications involved, as well as the client's response and outcome.
Choice D Reason:Rapidly measuring PT/INR and aPTT provides objective evidence of anticoagulation level after dual therapy. These results directly influence urgent clinical decisions, such as holding anticoagulants, administering reversal agents, or preparing for interventions to control bleeding, making this the highest‑priority action.
Correct Answer is ["B","C"]
Explanation
Choice A Reason: Identifying locations of skin lesions on a newly admitted client is a nursing assessment that requires clinical judgment and cannot be delegated to the UAP.
Choice B Reason: Emptying the ostomy bag for a client with a temporary colostomy is a routine task that does not require clinical judgment and can be delegated to the UAP.
Choice C Reason: Providing a complete bed bath for a comatose client is a routine task that does not require clinical judgment and can be delegated to the UAP.
Choice D Reason: Performing foot care including toenail trimming and heel care is a nursing intervention that requires clinical judgment and cannot be delegated to the UAP. The UAP may cause injury or infection to the client's feet, especially if the client has diabetes or peripheral vascular disease.
Choice E Reason: Giving mouth care to an elderly client who has a tracheostomy is a nursing intervention that requires clinical judgment and cannot be delegated to the UAP. The UAP may cause trauma or aspiration to the client's trachea, especially if the client has poor oral hygiene or respiratory secretions.
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