A nurse is reviewing his client care assignments after receiving change-of-shift report. The nurse should notify the charge nurse that which of the following tasks should be reassigned to an RN?
Inserting an indwelling urinary catheter
Administering heparin subcutaneously
Suctioning a client's new tracheostomy
Classifying a pressure ulcer
The Correct Answer is C
A. Inserting an indwelling urinary catheter can be performed by licensed practical nurses (LPNs) under the supervision of an RN, so this task does not need to be reassigned.
B. Administering heparin subcutaneously is a task that can be performed by LPNs, so it does not require reassignment to an RN.
C. Suctioning a client's new tracheostomy is a more complex procedure that requires advanced skills and assessment, making it appropriate for an RN rather than an LPN.
D. Classifying a pressure ulcer is a task that can be done by both RNs and LPNs, so it does not need to be reassigned.
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Correct Answer is A
Explanation
A. Obtaining the client's capillary blood glucose level is the first action because it determines the appropriate timing and dosage of insulin administration, ensuring safe and effective diabetes management.
B. Administering prescribed insulin should occur after assessing the client's blood glucose level to avoid the risk of hypoglycemia or hyperglycemia.
C. Providing the client's breakfast is important but should only occur after assessing blood glucose and administering insulin as needed to maintain stable glucose levels.
D. Checking the calibration of the glucometer is essential for accurate readings but does not directly address the immediate need to assess the client's glucose level.
Correct Answer is D
Explanation
A. Consulting the ethics committee is unnecessary at this stage, as there is no ethical dilemma in arranging social support services.
B. Suggesting a discharge delay is premature and may not be feasible; alternative support should be considered first.
C. Long-term care facility placement is a more permanent solution and may not align with the client’s needs or preferences.
D. Recommending a referral to social services is appropriate as social services can help arrange post-discharge support, including home health services or community resources, ensuring a safe transition home.