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The charge nurse plans client care assignments for an unlicensed assistive personnel (UAP) and a licensed practical/vocational nurse (LPN/VN) in the medical-surgical unit. Which activity should the charge nurse delegate to the LPN/VN to maximize staff resources?
- A. Perform wound care and dressing changes
- B. Collect routine vital signs (VS)
- C. Turn all bedbound clients every two hours
- D. Ambulate clients with ambulation orders
Correct Answer: A
Rationale: Wound care and dressing changes (A) utilize the LPN/VN’s clinical skills, maximizing resources. Vital signs (B), turning (C), and ambulation (D) are within UAP scope, allowing the LPN/VN to focus on higher-skill tasks.
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The nurse has obtained assistance from a licensed practical/vocational nurse (LPN/VN). Which tasks would be appropriate for the RN to delegate to the LPN/VN? Select all that apply.
- A. performing tracheostomy care
- B. initiate a transfusion of packed red blood cells
- C. flushing a peripherally inserted central catheter (PICC)
- D. inserting an indwelling urinary catheter
- E. administer enteral feedings via nasogastric tube
- F. titrate a medication
Correct Answer: A, C, D, E
Rationale: LPNs can perform tracheostomy care (A), flush PICCs (C), insert urinary catheters (D), and administer enteral feedings (E) per scope of practice. Initiating blood transfusions (B) and titrating medications (F) require RN judgment due to potential complications and dose adjustments.
A nurse is delegating tasks to the unlicensed assistive personnel (UAP). Which task is most appropriate for the UAP to perform?
- A. Assisting a client with dysphagia during oral feedings.
- B. Documenting a client’s response to a medication administered for pain relief.
- C. Collecting a clean-catch urine sample from a client.
- D. Removing a client’s indwelling urinary catheter per the provider’s order.
Correct Answer: C
Rationale: Collecting a clean-catch urine sample (C) is a non-invasive task within the UAP’s scope. Feeding with dysphagia (A), documenting medication response (B), and catheter removal (D) require clinical judgment or training beyond UAP scope.
The nurse has been made aware of the following client situations. The nurse should first assess the client who has
- A. bacterial meningitis and is receiving a third dose of intravenous doxycycline and reports a rash on their torso.
- B. a cerebral aneurysm and is nervous about their scheduled surgery in one hour.
- C. amyotrophic lateral sclerosis (ALS) and coughs when attempting to eat and drink.
- D. a migraine headache and has developed flushing after receiving prescribed intranasal sumatriptan.
Correct Answer: A
Rationale: A rash during doxycycline for meningitis (A) suggests a possible allergic reaction, a life-threatening complication requiring immediate assessment. Pre-surgical anxiety (B), ALS coughing (C), and sumatriptan flushing (D) are less acute, as they are expected or stable.
The nurse is caring for the following assigned clients. The nurse should immediately follow up with the client who has
- A. mechanical ventilation and the low-pressure alarm sounds.
- B. a new colostomy with refusal to participate in care.
- C. acute glomerulonephritis and has periorbital edema.
- D. atrial fibrillation with an irregular pulse.
Correct Answer: A
Rationale: A low-pressure ventilator alarm (D) suggests a leak or disconnection, risking airway compromise, requiring immediate follow-up. Colostomy refusal (A), periorbital edema (B), and irregular pulse in AF (C) are less urgent, as they are chronic or stable.
The nurse enters a client's room and finds the client lying on the floor and appearing unresponsive. The nurse should initially
- A. initiate a code blue.
- B. assess the client's respiratory effort.
- C. assess the carotid pulse.
- D. shout the client's name.
Correct Answer: B
Rationale: Assessing respiratory effort (B) is the initial step for an unresponsive client to determine if breathing is present, guiding further action. Shouting (D), checking pulse (C), or initiating a code (A) follow assessment.