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A nurse and an experienced licensed practical nurse (LPN) are caring for a group of clients. Which of the following tasks should the nurse delegate to the LPN? (Select all that apply)
- A. Plan a plan of care for a client when postoperative from an appendectomy
- B. Provide discharge instructions to a confused client’s spouse
- C. Administer a tap-water enema to a client who is preoperative
- D. Clean vital signs from a client who is 6 hours postoperative
- E. Catheterize a client who has not voided in 8 hours
Correct Answer: C,D,E
Rationale: The correct tasks to delegate to the LPN are C, D, and E. For choice C, administering a tap-water enema to a preoperative client falls within the LPN's scope of practice as it involves a routine procedure that does not require advanced assessment or critical thinking skills. Choice D, cleaning vital signs from a client who is 6 hours postoperative, is a task that can be safely delegated to the LPN as it involves routine monitoring that does not require RN-level judgment. Choice E, catheterizing a client who has not voided in 8 hours, is a task that the LPN can perform as it is a straightforward procedure that the LPN would have been trained to do. Choices A and B involve more complex decision-making and education that are typically within the RN's scope of practice.
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A home health nurse is assessing an older adult client in the home who has decreased vision due to a history of glaucoma. Which of the following findings should the nurse identify as a safety risk?
- A. Handrails are present in the bathroom.
- B. Electrical cords are placed along the walls.
- C. Uses a microwave for cooking.
- D. Scatter rugs are present in the kitchen.
Correct Answer: D
Rationale: The correct answer is D: Scatter rugs are present in the kitchen. Scatter rugs can pose a safety risk for an older adult with decreased vision due to glaucoma as they increase the risk of tripping and falling. The uneven surface and lack of secure placement make scatter rugs hazardous. Handrails in the bathroom (A) enhance safety, electrical cords along the walls (B) may be a tripping hazard but can be easily addressed, and using a microwave for cooking (C) is a safe and convenient option for someone with decreased vision.
A nurse is assessing a client who is receiving metoprolol. Which of the following indicates a therapeutic effect?
- A. Decreased blood pressure.
- B. Decreased dysrhythmias.
- C. Increased urine output.
- D. Decreased pulse.
Correct Answer: A
Rationale: The correct answer is A: Decreased blood pressure. Metoprolol is a beta-blocker that works by reducing heart rate and decreasing the workload on the heart, leading to a decrease in blood pressure. This is a therapeutic effect as it helps manage conditions like hypertension and angina.
Incorrect choices:
B: Decreased dysrhythmias - While metoprolol can help reduce dysrhythmias, the primary therapeutic effect is on blood pressure.
C: Increased urine output - Metoprolol does not directly affect urine output.
D: Decreased pulse - Decreasing pulse is a common side effect of metoprolol, but the therapeutic effect is primarily on blood pressure.
A nurse is providing discharge teaching to a client who has a new diagnosis of heart failure. Which of the following instructions should the nurse include in the teaching?
- A. Take naproxen for generalized discomfort
- B. Notify the provider of a weight gain of 0.5 kg (1 lb) in a week
- C. Take diuretics early in the morning and before bedtime
- D. Exercise at least three times per week
Correct Answer: B
Rationale: The correct answer is B: Notify the provider of a weight gain of 0.5 kg (1 lb) in a week. This is crucial in heart failure management as sudden weight gain can indicate fluid retention, worsening heart failure, and the need for medication adjustment. Option A is incorrect as naproxen can worsen heart failure symptoms. Option C is incorrect as diuretics should be taken in the morning to prevent nighttime urination. Option D is incorrect as the frequency and intensity of exercise should be tailored based on the individual's condition.
A nurse is caring for a child who is admitted with suspected acute appendicitis. Which of the following manifestations should indicate to the nurse that the child’s appendix is perforated?
- A. Sudden decrease in abdominal pain.
- B. Absence of Rovsing’s sign.
- C. Low-grade fever.
- D. Rigid abdomen.
Correct Answer: A
Rationale: The correct answer is A: Sudden decrease in abdominal pain. A sudden decrease in abdominal pain can indicate a perforated appendix due to the release of pressure and inflammation. This sudden relief occurs when the appendix ruptures, causing the abdominal pain to subside temporarily. This is a critical sign that the appendix has perforated and requires immediate medical attention. The other choices are incorrect because: B: Absence of Rovsing’s sign is not specific to a perforated appendix. C: Low-grade fever is commonly seen in uncomplicated appendicitis and may not necessarily indicate perforation. D: A rigid abdomen is a sign of peritonitis, which can occur with a perforated appendix, but it is not as specific as the sudden decrease in pain.
A charge nurse is making a room assignment for a client who has scabies. In which of the following rooms should the nurse place the client?
- A. A negative-pressure isolation room.
- B. A private room.
- C. A semi-private room with a client who has pediculosis capitis.
- D. A positive-pressure isolation room.
Correct Answer: B
Rationale: The correct answer is B: A private room. This is appropriate for a client with scabies to prevent the spread of the infestation to others. A private room allows for isolation and reduces the risk of transmission to other clients.
A: A negative-pressure isolation room is typically used for clients with airborne infections to prevent the spread of pathogens outside the room. Scabies is not transmitted through the air.
C: Placing the client in a semi-private room with a client who has pediculosis capitis (head lice) is not ideal as both conditions are caused by different parasites and may increase the risk of cross-contamination.
D: A positive-pressure isolation room is used for clients who need protection from outside pathogens, not for containing contagious conditions like scabies.
In summary, a private room is the best choice for a client with scabies to prevent transmission to others, while the other options are not appropriate due to the nature of scabies and the need for isolation.