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A nurse is caring for an older adult client who is disoriented and has a history of falls. Which of the following actions should the nurse take? (Select all that apply.)
- A. Apply an ambulation alarm to the client's leg.
- B. Obtain a prescription to restrain the client PRN.
- C. Instruct the client in the use of the call light.
- D. Raise all side rails on the client's bed.
- E. Check on the client hourly.
Correct Answer: A,C,E
Rationale: The correct actions are A, C, and E. Applying an ambulation alarm to the client's leg helps prevent falls by alerting staff when the client attempts to get out of bed. Instructing the client in the use of the call light promotes safety by enabling them to request assistance when needed. Checking on the client hourly allows for monitoring and timely intervention if the client is at risk of falling. Choice B, obtaining a prescription to restrain the client PRN, is incorrect as physical restraints can have adverse effects and should be used as a last resort. Choice D, raising all side rails on the client's bed, is incorrect because it may lead to feelings of confinement and is not recommended as a fall prevention strategy.
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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.
An RN is making nursing staff assignments for his team consisting of himself, two licensed practical nurses (LPNs), and an assistive personnel (AP). Which of the following clients should he assume responsibility for?
- A. The client who is in protective isolation
- B. The client who is actively dying and requires IV pain medication
- C. The client who is 3 days postoperative and requires a dressing change
- D. The client who requires frequent ambulation
Correct Answer: B
Rationale: The correct answer is B: The client who is actively dying and requires IV pain medication. The RN should assume responsibility for this client because as the registered nurse, they are the most qualified to manage complex care needs, such as IV pain medication administration and end-of-life care. The RN's advanced knowledge and skills make them best suited to provide appropriate assessment, intervention, and coordination of care in this critical situation.
Choice A is incorrect because the client in protective isolation requires meticulous adherence to infection control practices, which can be safely delegated to the LPNs or AP under the RN's supervision.
Choice C is incorrect as a dressing change for a client 3 days postoperative is within the scope of practice for the LPNs or AP and does not require the RN's direct involvement.
Choice D, the client requiring frequent ambulation, can be delegated to the LPNs or AP, as this task does not require the RN's specialized skill set.
A charge nurse is evaluating the performance of an assistive personnel (AP). Which of the following actions by the AP indicates a need for further education?
- A. The AP reports a client's temperature of 38.5°C to the nurse.
- B. The AP assists a client with turning every 2 hours.
- C. The AP leaves a client's meal tray out of reach after delivery.
- D. The AP uses a gait belt when ambulating a client.
Correct Answer: C
Rationale: Leaving the meal tray out of reach prevents the client from eating, indicating a need for further education on client-centered care. The other actions are appropriate.
A nurse manager has recently become aware of a conflict between the pharmacy and the staff nurses regarding sending and receiving medications. Which of the following actions should the nurse take first to resolve the conflict?
- A. Evaluate the results.
- B. Brainstorm solutions.
- C. Implement a resolution.
- D. Identify the problem
Correct Answer: D
Rationale: The correct answer is D: Identify the problem. This is the first step in conflict resolution as it allows the nurse manager to understand the root cause of the conflict between pharmacy and staff nurses. By identifying the problem, the nurse manager can gather relevant information, perspectives, and concerns from both parties. This step is crucial in developing an effective resolution strategy.
Choice A (Evaluate the results) is incorrect as evaluation should come after identifying the problem. Choice B (Brainstorm solutions) is premature without understanding the underlying issue. Choice C (Implement a resolution) should not be done before identifying the problem to ensure the solution addresses the actual conflict.
A nurse on a medical-surgical unit is providing care for a group of clients. The nurse should delegate collection of which of the following specimens to the assistive personnel (AP)?
- A. Blood for PaCO2
- B. Random stool specimen
- C. Wound drainage for culture
- D. Urine from an indwelling catheter
Correct Answer: B
Rationale: The correct answer is B: Random stool specimen. The rationale is that collecting a random stool specimen does not require specialized training or skills, making it appropriate for assistive personnel (AP) to perform. Collecting blood for PaCO2 (A) requires specific training and knowledge of arterial blood gas sampling. Wound drainage for culture (C) involves sterile technique and knowledge of wound care. Urine from an indwelling catheter (D) requires knowledge of catheter care and sterile technique. Therefore, delegating the collection of a random stool specimen to AP is the most appropriate choice.