A nurse is planning care for a group of clients at the beginning of the shift. Which of the following tasks should the nurse assign to the licensed practical nurse (LPN)?
Analyzing data to identify issues for a client who has uncontrolled diabetes mellitus
Assisting a client with crutch walking following knee replacement surgery
Evaluating the outcomes of a new postoperative client
Developing the plan of care for a client who has an amputation
The Correct Answer is B
Rationale:
A. Analyzing data to identify issues for a client who has uncontrolled diabetes mellitus requires a higher level of clinical judgment and is typically performed by an RN.
B. Assisting a client with crutch walking following knee replacement surgery is an appropriate task for an LPN, as it involves support with activities of daily living and mobility.
C. Evaluating the outcomes of a new postoperative client involves assessing the effectiveness of care and requires RN-level assessment skills.
D. Developing the plan of care for a client who has an amputation involves comprehensive assessment and planning, which is usually the responsibility of an RN.
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Correct Answer is D
Explanation
Rationale:
A. Capillary refill time of 4 seconds is concerning but less urgent compared to immediate post-catheter removal issues.
B. Fruity breath odor in late-stage cirrhosis could indicate a metabolic issue but is less immediate than issues related to urinary output.
C. Green gastric aspirate with a pH of 5.3 is within normal range for NG tube decompression.
D. A client who has not voided 5 hours after catheter removal is at risk for urinary retention or other complications and should be assessed immediately.
Correct Answer is ["A","C","E"]
Explanation
Rationale:
A. Applying an ambulation alarm can help alert staff if the client tries to move independently, thus reducing the risk of falls.
B. Restraints should only be used as a last resort and require a physician’s order. They should not be used routinely for fall prevention.
C. Instructing the client in the use of the call light empowers them to request assistance, which can help prevent falls.
D. Raising all side rails can be considered a restraint and may increase the risk of falls or injury. It is not a recommended practice for fall prevention.
E. Checking on the client hourly ensures ongoing monitoring and timely intervention if needed, which is effective in preventing falls.