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The nurse is planning client assignments in the mental health unit. Which task should the nurse delegate to the licensed practical/vocational nurse (LPN/VN)?
- A. conduct a suicide assessment on a newly admitted client
- B. administering prescribed lithium to a client with bipolar disorder
- C. leading a group therapy session for clients with depressive disorders
- D. monitoring a client who is talking on the phone to a family member
Correct Answer: B
Rationale: Administering prescribed lithium (B) is within the LPN’s scope, involving medication administration to a stable client. Suicide assessment (A) and group therapy (B) require RN expertise, and monitoring phone calls (C) is a UAP task, making these inappropriate for LPN delegation (D).
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The nurse is caring for the following assigned clients. It would be a priority for the nurse to assess the client
- A. being evaluated for chest pain and requesting an antacid for indigestion.
- B. reporting nervousness following the administration of albuterol.
- C. requesting pain medication for their chronic knee and back pain.
- D. awaiting discharge teaching on their insulin pump and glucometer.
Correct Answer: A
Rationale: Chest pain with indigestion (A) may indicate a cardiac event, requiring immediate assessment to rule out myocardial infarction. Nervousness from albuterol (B) is a common side effect, chronic pain (C) is less urgent, and discharge teaching (D) can wait.
The charge nurse of a medical-surgical unit is informed that the nursing unit is short-staffed. Which task should the charge nurse delay in order to meet all client needs?
- A. Medication administration
- B. Daily baths
- C. Vital sign collection
- D. Hourly safety rounds
Correct Answer: B
Rationale: Daily baths (B) can be delayed as they are non-essential for immediate client safety. Medication administration (A), vital signs (C), and safety rounds (D) are critical for client care and cannot be postponed.
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 is performing an assessment on an older adult. Which finding requires immediate followup?
- A. dysphagia
- B. stress incontinence
- C. dry, flaky skin
- D. hearing loss
Correct Answer: A
Rationale: Dysphagia (A) in older adults risks aspiration and malnutrition, requiring immediate follow-up to ensure safety. Stress incontinence (B), dry skin (C), and hearing loss (D) are common but less urgent concerns.