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An assistive personnel (AP) reports to the nurse that a client who is 3 days postoperative following an abdominal hysterectomy has a dressing that is saturated with blood. Which of the following tasks should the nurse delegate to the AP?
- A. Palpate for possible bladder distention.
- B. Observe the incision site.
- C. Change the abdominal dressing.
- D. Obtain vital signs.
Correct Answer: D
Rationale: The correct answer is D: Obtain vital signs. Vital signs are essential to assess the client's overall condition and determine the urgency of the situation. The AP can measure and report the vital signs to the nurse promptly. Palpating for bladder distention (choice A) requires a higher level of assessment and may indicate a complication postoperatively. Observing the incision site (choice B) involves assessing for signs of infection or other complications, which should be done by a nurse. Changing the abdominal dressing (choice C) requires sterile technique and assessment skills beyond the AP's scope. Therefore, delegating these tasks to the AP could delay necessary interventions.
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A nurse is caring for four clients on a medical-surgical unit. Which of the following clients should the nurse assess first?
- A. A client who has COPD and the capillary refill time on both hands is 4 seconds
- B. A client who has late-stage cirrhosis and whose breath has a fruity odor
- C. A client who has a nasogastric tube for decompression and the gastric aspirate is green with a pH of 5.3
- D. A client who had an indwelling urinary catheter removed 5 hr ago and has not voided
Correct Answer: D
Rationale: The correct answer is D. The nurse should assess the client who had an indwelling urinary catheter removed 5 hours ago and has not voided first. This situation raises concerns about urinary retention, which can lead to bladder distension, discomfort, and potential complications like urinary tract infections. Prompt assessment and intervention are necessary to prevent further issues.
Choice A is incorrect because a capillary refill time of 4 seconds in a client with COPD may suggest impaired circulation but is not as urgent as urinary retention. Choice B is incorrect as fruity odor in late-stage cirrhosis may indicate hepatic encephalopathy but is not an immediate priority. Choice C is incorrect as green gastric aspirate with a pH of 5.3 may indicate bile reflux but not as urgent as urinary retention.
A nurse is preparing to delegate tasks to a licensed practical nurse (LPN). Which of the following tasks is appropriate for the LPN to perform?
- A. Develop a care plan for a client with a new diagnosis of diabetes.
- B. Administer a prescribed subcutaneous insulin injection.
- C. Perform an admission assessment for a client with chest pain.
- D. Evaluate the effectiveness of a client's pain management plan.
Correct Answer: B
Rationale: The correct answer is B: Administer a prescribed subcutaneous insulin injection. LPNs are trained to administer medications, including insulin injections, under the supervision of a registered nurse or physician. LPNs have the knowledge and skills necessary to safely administer medications. Choices A, C, and D involve assessments, evaluations, and care planning, which are tasks typically performed by registered nurses. LPNs can assist with these tasks but should not independently perform them. Overall, LPNs are best suited to carry out tasks related to direct patient care, such as medication administration.
A nurse is assigned a group of clients at the start of the shift. Which of the following clients should the nurse plan to care for first?
- A. A client requesting a referral for home health services
- B. A client asking about his PCA pump that contains morphine
- C. A client who needs assistance with a bath
- D. A client who has questions about his new prescription
Correct Answer: B
Rationale: The correct answer is B. The nurse should plan to care for the client asking about his PCA pump with morphine first. This is because the client's inquiry relates to pain management, which is a priority in nursing care. Pain management directly impacts the client's comfort and well-being. Addressing the client's concerns about the PCA pump promptly ensures proper pain relief and prevents potential complications. Clients requesting referrals, assistance with baths, or questions about prescriptions can be attended to after the client with immediate pain management needs is addressed.
A home health nurse is planning care for a client who has Alzheimer's disease. The client's partner is her primary caregiver and reports not having enough time to complete his errands. Which of the following referrals should the nurse plan to make?
- A. Respite care
- B. Restorative care
- C. Hospice care
- D. Mental health care
Correct Answer: A
Rationale: The correct answer is A: Respite care. This is the most appropriate referral for the client's partner who needs time off from caregiving responsibilities to complete errands. Respite care provides temporary relief for the primary caregiver, allowing them to take a break while ensuring the client's needs are still met. This helps prevent caregiver burnout and promotes overall well-being for both the caregiver and the client.
Choices B, C, and D are incorrect:
B: Restorative care focuses on restoring the client's functional abilities and independence, which is not directly related to the partner's need for time off.
C: Hospice care is for clients with terminal illnesses who are no longer receiving curative treatment, which is not applicable in this scenario.
D: Mental health care may be beneficial for the client or caregiver in managing emotions and stress, but it does not address the immediate need for respite care.
A nurse is planning to use the SBAR communication tool when calling a provider. Which of the following statements should the nurse include in the B step?
- A. There are no provider's prescriptions available.
- B. The client was found unconscious on the floor in her home.
- C. The client should be seen by a neurologist.
- D. The client is disoriented. Pupils are slow to respond to light.
Correct Answer: D
Rationale: The correct answer is D because in the SBAR communication tool, the "B" step stands for Background. Reporting the client's disorientation and slow pupil response to light provides essential background information for the provider to understand the client's condition. This information helps the provider assess the urgency and severity of the situation. Choice A is incorrect because it does not provide relevant client information in the Background step. Choices B and C belong in the S (Situation) step as they directly relate to the client's current situation and recommended actions. Therefore, they are not appropriate for the Background step.