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RN is making assignments for client care to LPN at beginning of shift. Which of following assignments should LPN question?
- A. Assisting a client who is 24h post-op to use incentive spirometer
- B. Collecting clean-catch urine specimen from client who was admitted on previous shift
- C. Providing nasopharyngeal suctioning for client with pneumonia
- D. Replacing cartridge & tubing on PCA pump
Correct Answer: D
Rationale: The correct answer is D: Replacing cartridge & tubing on PCA pump. This is the assignment the LPN should question. The rationale is that LPNs are not typically trained to handle complex medical devices like PCA pumps, which deliver controlled doses of pain medication. LPNs should question this task as it involves intricate technical skills and potential risks if done incorrectly.
A: Assisting a client with an incentive spirometer is within an LPN's scope of practice and does not require specialized training.
B: Collecting a clean-catch urine specimen is a routine task that LPNs are typically trained to perform.
C: Providing nasopharyngeal suctioning for a client with pneumonia is a common nursing intervention that LPNs are qualified to carry out.
In summary, LPNs should question assignments that are outside their scope of practice or involve technical procedures beyond their training to ensure safe and effective care for the clients.
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Nurse has removed a sterile pack from its outside cover & placed it on a clean work surface in preparation for an invasive procedure. Which of the following flaps should the nurse unfold first?
- A. Flap closest to body
- B. Right side flap
- C. Left side flap
- D. Flap farthest from the body
Correct Answer: D
Rationale: The correct answer is D: Flap farthest from the body. Unfolding this flap first ensures that the sterile contents inside the pack remain protected from contamination by the nurse's body and hands. Starting with the farthest flap minimizes the risk of accidental touching or contamination of the sterile instruments or supplies. Unfolding the closest flap (choice A) or the side flaps (choices B and C) first could potentially expose the sterile contents to contamination. Therefore, unfolding the flap farthest from the body is the most appropriate and logical step to maintain sterility and ensure safe patient care during the procedure.
Nurse observes smoke coming from under door of staff lounge. Which is priority action by the nurse?
- A. Extinguish fire
- B. Pull fire alarm
- C. Evacuate the clients
- D. Close all open doors on the unit
Correct Answer: C
Rationale: The priority action for the nurse in this scenario is to evacuate the clients (Choice C). This is because ensuring the safety of the clients is the most critical responsibility in a healthcare setting. Evacuating them immediately helps prevent harm and ensures their well-being. Pulling the fire alarm (Choice B) may be necessary but not the top priority as it does not directly ensure client safety. Extinguishing the fire (Choice A) may put the nurse at risk and delay client evacuation. Closing doors (Choice D) may contain the fire but does not address the immediate need of client safety.
Nurse at elementary school is planning health promotion & primary prevention class. Which topics are appropriate for parents of school-age children?
- A. "childhood obesity"
- B. substance use disorders
- C. scoliosis screening
- D. front-seat seatbelt use
- E. stranger awareness
Correct Answer: A, B, C, E
Rationale: The correct topics for parents of school-age children are A, B, C, and E. A- Childhood obesity is relevant for promoting healthy habits. B- Substance use disorders prevention can educate parents on risks. C- Scoliosis screening is important for early detection. E- Stranger awareness is crucial for child safety. Choices D and any other options not selected are inappropriate as they do not directly relate to health promotion and primary prevention for school-age children.
Nurse is preparing a discharge summary for a client who had knee surgery and is going home. Which of the following info about the client should the nurse include in it? (Select all that apply.)
- A. Advance directives status
- B. Where to go for follow-up care
- C. Instructions for diet/meds
- D. Most recent vital sign data
- E. Contact info for home healthcare agency
Correct Answer: B,C,E
Rationale: The correct answers are B, C, and E.
B: Providing information on where to go for follow-up care ensures the client continues to receive proper medical attention post-surgery.
C: Instructions for diet/meds are crucial for the client's recovery and to prevent complications.
E: Providing contact info for a home healthcare agency ensures the client has access to additional support and care at home.
Incorrect answers:
A: Advance directives status is important but not directly related to immediate post-operative care.
D: Most recent vital sign data is important for monitoring but does not need to be included in a discharge summary.
Nurse admitting a client with acute cholecystitis to the med-surg unit. Which of the following actions are essential to the admission procedure? (Select all that apply.)
- A. Explain roles of other care delivery staff
- B. Begin discharge planning
- C. Provide info about advance directives
- D. Document the client's wishes about organ donation
- E. Introduce client to his roommate
Correct Answer: A,B,C,E
Rationale: Correct Answer: A, B, C, E
Rationale:
A: Explaining roles of other care delivery staff helps manage client expectations and ensures effective communication among healthcare team members.
B: Beginning discharge planning early improves continuity of care and helps prevent delays in the discharge process.
C: Providing information about advance directives ensures the client's wishes are documented and respected in case of incapacitation.
E: Introducing the client to his roommate promotes social interaction and helps create a comfortable environment for the client.
Summary:
Choice D is incorrect as documenting organ donation wishes is not directly related to the admission process for acute cholecystitis.