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A nurse is supervising a licensed practical nurse (PN) who is providing care to a client who is postoperative. Which of the following statements by the client requires the nurse to follow up with the PN?
- A. Do you know when I will be going home?
- B. My dressing was changed earlier this morning.
- C. I have not received any of my medications today.
- D. I do not know how to make the remote control work.
Correct Answer: C
Rationale: Correct Answer: C. "I have not received any of my medications today."
Rationale: This statement is concerning as it indicates a potential oversight in medication administration, which is crucial for postoperative clients. The nurse should follow up with the PN to ensure that the client receives the necessary medications promptly.
Summary of Other Choices:
A: Asking about discharge is appropriate and does not require immediate follow-up.
B: Reporting that the dressing was changed is a positive sign of wound care management.
D: Not knowing how to use the remote control is not a priority in postoperative care.
Overall, choice C stands out as it directly relates to the client's well-being and should be addressed promptly.
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An RN from the maternal-newborn unit is being floated to a medical-surgical unit. Which of the following clients should the charge nurse on the medical-surgical unit plan to assign to the RN?
- A. A client who has acute pancreatitis
- B. A client who is one-day postoperative following a total abdominal hysterectomy
- C. A client who had a stroke and is to be admitted
- D. A client who has terminal end-stage renal disease
Correct Answer: B
Rationale: The correct answer is B: A client who is one-day postoperative following a total abdominal hysterectomy. This assignment is appropriate because a nurse from the maternal-newborn unit would likely have experience with postoperative care, wound care, pain management, and monitoring for complications such as hemorrhage or infection. The nurse would also be knowledgeable about assessing vital signs, managing surgical drains, and providing education on postoperative care.
Choice A (acute pancreatitis) would require specific knowledge and skills related to the gastrointestinal system, which may not be within the RN's expertise from the maternal-newborn unit. Choice C (stroke admission) would require expertise in neurology and rehabilitation, which may not be the RN's area of focus. Choice D (end-stage renal disease) would require expertise in nephrology and dialysis, which may not be the RN's specialty.
Assigning the RN to a client who is postoperative following a total abdominal hysterectomy aligns with the RN's background in maternal
A nurse in the emergency department is caring for a client who has a compression fracture of a spinal vertebra. During transport to the facility, the client was medicated with intravenous morphine. On arrival, the neurosurgeon determined urgent surgical intervention is indicated for the fracture. Staff members have been unable to reach the client's family. Which of the following actions should the nurse anticipate the neurosurgeon taking?
- A. Prescribing naloxone to reverse the effects of the morphine
- B. Asking the client to sign the surgical consent form
- C. Delaying the surgery until a member of the client's family is reached
- D. Invoking implied consent
Correct Answer: D
Rationale: The correct answer is D: Invoking implied consent. Implied consent allows healthcare providers to proceed with urgent treatment when a patient is unable to provide informed consent and there is an immediate threat to the patient's life or health. In this scenario, the client requires urgent surgical intervention for a compression fracture, and the family cannot be reached. Therefore, the neurosurgeon may invoke implied consent to proceed with the surgery to prevent further harm to the client.
A: Prescribing naloxone to reverse the effects of the morphine is not necessary in this case as the morphine was given for pain management and does not interfere with the need for urgent surgical intervention.
B: Asking the client to sign the surgical consent form is not appropriate as the client may not be in a condition to provide informed consent due to the urgent nature of the surgery and the effects of the medication.
C: Delaying the surgery until a member of the client's family is reached may not be feasible if there
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.
A charge nurse has assigned a group of clients to a licensed practical nurse (LPN). The charge nurse receives reports from her assigned clients about the LPN's lack of care. Which of the following actions should the charge nurse take?
- A. Discuss the LPN's behavior with other nurses on the unit.
- B. Review the LPN's personnel file.
- C. Talk with the clients who have reported the LPN's lack of care.
- D. Reassign some of the LPN's client care to assistive personnel.
Correct Answer: B
Rationale: The correct answer is B: Review the LPN's personnel file. The charge nurse should investigate the LPN's background, qualifications, and performance history to address the reported lack of care. This step is crucial to understand any patterns or issues that may be contributing to the problem. Discussing the LPN's behavior with other nurses (Choice A) may lead to gossip and bias. Talking with the clients (Choice C) may not provide a complete picture and could breach confidentiality. Reassigning client care (Choice D) without addressing the root cause is not a sustainable solution.
A nurse is planning care for four clients and is assigning tasks to a licensed practical nurse (LPN) and an assistive personnel (AP). Which of the following should the nurse assign to the LPN?
- A. Measure 1&O for a client who has an indwelling urinary catheter.
- B. Reinforce teaching to a client to begin taking enoxaparin at home following a hip arthroplasty.
- C. Develop a plan of care for a client who has cholecystitis.
- D. Complete an admission assessment for a client who has COPD.
Correct Answer: B
Rationale: The correct answer is B because reinforcing teaching to a client about medication administration falls within the scope of practice for an LPN. LPNs are trained to provide education on medication administration and can reinforce teaching provided by the nurse.
Choice A is incorrect because measuring intake and output for a client with an indwelling urinary catheter requires specific nursing assessment skills that LPNs may not have.
Choice C is incorrect because developing a plan of care for a client with cholecystitis involves critical thinking and decision-making skills typically performed by a registered nurse.
Choice D is incorrect as completing an admission assessment for a client with COPD requires comprehensive assessment skills that are typically within the scope of practice for a registered nurse.
Therefore, choice B is the most appropriate task to assign to an LPN in this scenario.