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A nurse is caring for a client who is experiencing chest pain. Which of the following actions should the nurse take first?
- A. Administer prescribed nitroglycerin.
- B. Obtain a 12-lead ECG.
- C. Notify the provider of the chest pain.
- D. Assess the client's pain characteristics.
Correct Answer: D
Rationale: Assessing the client's pain characteristics provides critical data to guide further actions, such as medication administration or diagnostic testing, and is the first step in managing chest pain.
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At the beginning of the shift, an RN is preparing assignments for a licensed practical nurse (LPN) and an assistive personnel (AP). Which of the following tasks should the nurse assign to the LPN?
- A. Measuring a client's 1&O
- B. Obtaining a client's weight
- C. Providing postmortem care for a client
- D. Inserting a nasogastric tube for a client
Correct Answer: D
Rationale: Correct Answer: D - Inserting a nasogastric tube for a client
Rationale: LPNs are trained to perform more complex nursing tasks than APs. Inserting a nasogastric tube requires specialized skills and knowledge that LPNs are educated and licensed to carry out safely. LPNs have the training to assess, insert, and manage nasogastric tubes under the supervision of an RN, making this task appropriate for delegation to an LPN.
Incorrect Choices:
A: Measuring a client's 1&O - This task can be safely performed by an AP as it does not require the clinical judgment and skills of an LPN.
B: Obtaining a client's weight - This is within the scope of practice for an AP and does not require the nursing expertise of an LPN.
C: Providing postmortem care for a client - This task involves specialized knowledge and emotional support, typically handled by RNs, not LPNs.
A nurse is caring for a client who is terminally ill and has a do-not-resuscitate (DNR) order. The client's family requests that the nurse withhold pain medication to hasten death. Which of the following responses by the nurse is appropriate?
- A. I'll discuss this with the provider to see what we can do.
- B. Withholding medication to hasten death is not ethical or legal.
- C. Let me get the hospital chaplain to talk with you about this.
- D. I understand your wishes, but I need to follow the client's care plan.
Correct Answer: B
Rationale: Correct Answer: B. Withholding medication to hasten death is not ethical or legal.
Rationale: As a nurse, it is important to uphold ethical principles and follow legal guidelines. Withholding pain medication to hasten death goes against the principle of beneficence, which focuses on doing good for the patient. It also contradicts the principle of nonmaleficence, which emphasizes avoiding harm. Additionally, hastening death through medication is illegal and violates the client's right to receive appropriate care. By choosing this response, the nurse demonstrates ethical integrity and ensures the client's well-being is prioritized.
Summary:
A: Involving the provider is important but does not address the ethical and legal issues at hand.
C: Involving the chaplain may offer emotional support but does not address the ethical dilemma.
D: Following the client's care plan is essential, but in this case, the care plan should not include hastening death.
Overall, response B is the most appropriate as it
A nurse on the pediatric unit is providing room assignments for children who are to be admitted to the unit. The nurse should plan to place a child who is postoperative from an appendectomy with which of the following clients?
- A. A child who is experiencing sickle cell crisis
- B. A child who has a head injury
- C. A child who has a new diagnosis of type 1 diabetes mellitus
- D. A child who has streptococcal pharyngitis
Correct Answer: C
Rationale: The correct answer is C. Placing the postoperative appendectomy child with a child who has a new diagnosis of type 1 diabetes mellitus is appropriate because both conditions typically require close monitoring but do not pose an immediate risk to each other. The child with appendectomy may need pain management and wound care, while the child with diabetes may need monitoring of blood glucose levels and insulin administration. Placing the postoperative child with a child experiencing sickle cell crisis (A) could be risky due to the potential for infection and stress on both children. Placing the child with a head injury (B) with a postoperative child could be dangerous as the child with a head injury may need a quiet environment and close monitoring for any neurological changes. Placing the child with streptococcal pharyngitis (D) with a postoperative child could increase the risk of infection for the postoperative child.
A nurse is receiving change-of-shift report at the start of the shift. Which of the following statements by the nurse giving report indicates to the oncoming nurse that she should assume total care for the client, rather than assigning tasks to the assistive personnel (AP)?
- A. The client works in the hospital radiology department.
- B. The client discussed having prior thoughts of suicide.
- C. The client's blood pressure and pulse have been fluctuating throughout the day.
- D. The client's family members have been present most of the day.
Correct Answer: C
Rationale: The correct answer is C because fluctuating blood pressure and pulse indicate unstable vital signs requiring close monitoring and immediate intervention. The nurse giving report is indicating that the client's condition is dynamic and may require frequent assessments and interventions, which necessitates the oncoming nurse assuming total care. Choices A, B, and D do not directly imply the need for total care and could potentially be managed by assistive personnel.
A nurse is planning to assign tasks for a group of clients. Which of the following tasks should the nurse plan to assign to an assistive personnel (AP)? (Select all that apply.)
- A. Ambulate an older adult client who has hypertension.
- B. Provide discharge instructions for a client who has a new skin graft.
- C. Check a blood product with another nurse prior to administration.
- D. Weigh a client who has heart failure.
- E. Perform an admission assessment on a client.
Correct Answer: A,D
Rationale: The correct tasks to assign to an assistive personnel (AP) are A and D. APs are trained to assist with basic care activities. Ambulating an older adult client with hypertension and weighing a client with heart failure are within the scope of practice for APs as they do not involve complex assessments or critical decision-making. Providing discharge instructions (B) requires specialized knowledge and education, which is beyond the scope of an AP. Checking a blood product (C) and performing an admission assessment (E) require specific training and expertise that only licensed nurses should perform.