The nurse is caring for a group of clients with the help of a practical nurse (PN). Which nursing action(s) should the nurse assign to the PN? (Select all that apply)

Obtain postoperative vital signs for a client one day following unilateral knee arthroplasty.

Perform daily surgical dressing change for a client who had an abdominal hysterectomy.

Initiate patient controlled analgesia (PCA. pumps for two clients immediately postoperatively.

Start the second blood transfusion for a client twelve hours following a below knee amputation.

Monitor a dose of warfarin per protocol for a client with type 2 diabetes mellitus (DM).

Answer and Explanation

Correct Answer : A,B,E

Choice C reason: Initiating patient controlled analgesia (PCA. pumps for two clients immediately postoperatively is not a nursing action that can be assigned to the PN. PCA pump is a device that allows the client to self-administer pain medication through an IV line by pressing a button. PCA pump should be initiated by the nurse after verifying the prescription, setting the parameters, educating the client, and ensuring safety and effectiveness. The PN does not have the authority or competency to initiate PCA pump or adjust its settings.

Choice D reason: Starting the second blood transfusion for a client twelve hours following a below knee amputation is not a nursing action that can be assigned to the PN. Blood transfusion is a procedure that delivers donated blood or blood products into the client's bloodstream through an IV line. Blood transfusion should be started by the nurse after verifying the prescription, checking the blood type and compatibility, obtaining informed consent, and monitoring for any adverse reactions. The PN does not have the authority or competency to start blood transfusion or manage its complications.

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Correct Answer is C

Explanation

Choice A reason: Securing chest tube to the stretcher for transport is not the most important action for the nurse to take. Chest tube is a device that drains air or fluid from the pleural space or mediastinum after surgery or trauma. Securing chest tube to the stretcher can prevent accidental dislodgement or kinking of the tube during transport, but it is not as crucial as maintaining proper drainage.

Choice B reason: Marking the amount of chest drainage on the container is not the most important action for the nurse to take. Chest drainage is the fluid or air that collects in the chest tube container after being drained from the pleural space or mediastinum. Marking the amount of chest drainage on the container can help monitor fluid balance and detect excessive bleeding or leakage, but it is not as vital as ensuring proper drainage.

Choice D reason: Administering PRN pain medication prior to transport is not a timely action for the nurse to take. Pain medication is a drug that relieves pain by blocking pain signals or reducing inflammation. Administering pain medication prior to transport can improve comfort and reduce anxiety for the client, but it is not as urgent as preventing complications.

A. Inspect feet every month for ingrown nails, cuts, and calluses. B. Arrange diet schedule around three regular meals a day. C. Get an eye examination with an ophthalmologist annually. D. Using salt, herbs, and spices will improve the flavor of foods.

Correct Answer is C

Explanation

Choice A: Inspecting feet every month for ingrown nails, cuts, and calluses is not a statement that indicates understanding, as this is not frequent enough for a client with diabetes who may have impaired sensation and circulation in their feet. The recommended frequency is daily or at least weekly. This is an incorrect choice.

Choice B: Arranging diet schedule around three regular meals a day is not a statement that indicates understanding, as this may not be adequate for a client with diabetes who needs to balance their carbohydrate intake and blood glucose levels throughout the day. The recommended schedule is to have smaller and more frequent meals and snacks. This is another incorrect choice.

Choice C: Getting an eye examination with an ophthalmologist annually is a statement that indicates understanding, as this can help detect and prevent diabetic retinopathy, which can cause vision loss and blindness. Therefore, this is the correct choice.

Choice D: Using salt, herbs, and spices will improve the flavor of foods is not a statement that indicates understanding, as this may not be healthy for a client with diabetes who needs to limit their sodium intake and avoid potential interactions between herbs and medications. The recommended strategy is to use low-sodium seasonings and natural flavors. This is another incorrect choice.

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The nurse is caring for a group of clients with the help of a practical nurse (PN). Which nursing action(s) should the nurse assign to the PN? (Select all that apply)

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Naxlex Comprehensive Predictor Exams

A client is being urgently transported to radiology for a Computerized Tomography (CT scan) after a sudden decrease in level of consciousness. Theclient is orally intubated and has a left lateral chest tube to 20 cm suction. Which action is most important for the nurse to take?

Correct Answer is C

Explanation

The nurse is providing teaching to a client with type 2 diabetes mellitus about important points for disease and symptom management. Which statement by the client indicates understanding?

Correct Answer is C

Explanation

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