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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.
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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.
A nurse is caring for a client who has a history of dementia. The client is alert and oriented to person, place, and time, and has advance directives. The client is scheduled for a procedure that requires informed consent. Which of the following persons should sign the informed consent?
- A. The client
- B. The client's son, who has a durable power of attorney
- C. The client's partner
- D. The client's daughter, who is the primary caregiver
Correct Answer: A
Rationale: The correct answer is A: The client. Informed consent must be given by the client themselves, as they are alert, oriented, and have advance directives. This ensures that the client fully understands the procedure, risks, benefits, and alternatives before giving consent. The client's autonomy and right to make decisions about their own healthcare are paramount. The other choices are incorrect because only the client themselves can provide informed consent in this scenario. The son with durable power of attorney may make decisions when the client is unable to, but since the client is alert and oriented, they should sign the consent. The partner and daughter do not have the authority to provide informed consent on behalf of the client.
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 nurse is preparing to discharge a client who has a new prescription for warfarin. Which of the following tasks should the nurse delegate to an assistive personnel (AP)?
- A. Teach the client about dietary restrictions with warfarin.
- B. Provide the client with written discharge instructions.
- C. Assist the client with packing personal belongings.
- D. Schedule a follow-up appointment for the client.
Correct Answer: C
Rationale: Assisting the client with packing personal belongings is a non-clinical task within the AP's scope of practice. Teaching, providing instructions, and scheduling appointments require nursing expertise.
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