The practical nurse (PN) is assigning tasks to an unlicensed assistive personnel (UAP) who is giving basic care to a group of residents in a long-term care facility. Which client's task should be completed by a PN, rather than the UAP?
A client with continuous urinary bladder irrigation via a 3-way catheter.
A client with urinary urgency and incontinence who is asking for a bedpan.
A client with a full urinary bedside drainage unit after receiving a diuretic.
A client with paraplegia who needs an urinary condom-catheter change.
The Correct Answer is A
A client with continuous urinary bladder irrigation via a 3-way catheter: This task requires specialized knowledge and skill to ensure proper management of the irrigation process, monitoring for complications, and adjusting the irrigation rate as needed. It falls within the scope of practice of the PN, who has the necessary training and expertise.
B. A client with urinary urgency and incontinence who is asking for a bedpan: This task can be safely and appropriately assigned to the UAP. Assisting the client with using a bedpan for voiding is a basic care task that does not require specialized nursing knowledge or skills.
C. A client with a full urinary bedside drainage unit after receiving a diuretic: Emptying a full urinary bedside drainage unit is a task that can be assigned to the UAP. It involves routine emptying and documentation of the drainage bag and does not require specialized nursing knowledge or skills.
D. A client with paraplegia who needs a urinary condom-catheter change: This task requires specialized knowledge and skill to perform a sterile procedure, ensure proper placement and securement of the condom catheter, and assess for any complications. It falls within the scope of practice of the PN, who has the necessary training and expertise.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
This is the most important complication for the practical nurse (PN) to anticipate because it is a common and potentially life-threatening condition that can occur in clients with severe burns. Curling's ulcer, also known as stress ulcer, is a type of peptic ulcer that develops in the stomach or duodenum as a result of stress, shock, trauma, or burns. It is caused by decreased blood flow and increased acid secretion in the gastrointestinal tract, which damages the mucosal lining and leads to ulceration and bleeding.
The PN should anticipate Curling's ulcer in a client who experienced partial-thickness burns over 30% of the body surface area (BSA) 3 days ago, as this is a major risk factor for developing stress ulcers. The PN should monitor the client for signs and symptoms of Curling's ulcer, such as abdominal pain, nausea, vomiting, hematemesis, melena, and anemia. The PN should also administer prophylactic medications such as antacids, histamine-2 blockers, or proton pump inhibitors as prescribed by the health care provider.
Correct Answer is B
Explanation
Monitoring the client's vital signs, including temperature, heart rate, respiratory rate, and blood pressure, is crucial to assess for any signs of infection or complications following surgery.
A. While fluid volume intake and output are important to monitor for overall hydration status, it is not the most immediate concern after reinforcing the dressing.
C. Similarly, assessing the volume of peripheral pulses is important to evaluate peripheral perfusion, but it may not be the highest priority at this time.
D. Incisional pain scale rating is important to assess the client's comfort and pain level, but it should be done after ensuring the security of the surgical dressing.
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