A registered nurse (RN) and an experienced licensed practical nurse (LPN) are caring for a group of clients. Which of the following tasks should the RN delegate to the LPN? SELECT ALL THAT APPLY
Monitoring vital signs of postoperative clients.
Administering routine medications to stable clients.
Performing wound care on a client with a Stage III pressure ulcer.
Developing a teaching plan for a client newly diagnosed with Type II Diabetes.
Providing oral care to an unconscious client.
Correct Answer : A,B,C,E
Choice A reason:
Monitoring vital signs of postoperative clients is a task that can be safely delegated to an experienced LPN. LPNs are trained to monitor and report vital signs, which is a routine and essential part of postoperative care. This task does not require the advanced assessment skills of an RN, making it appropriate for delegation.
Choice B reason:
Administering routine medications to stable clients is within the scope of practice for LPNs. They are trained to administer medications and monitor clients for adverse reactions. As long as the clients are stable and the medications are routine, this task can be delegated to an LPN.
Choice C reason:
Performing wound care on a client with a Stage III pressure ulcer is a task that an experienced LPN can perform. LPNs are skilled in wound care and can manage complex dressings and treatments under the supervision of an RN. This delegation allows the RN to focus on more complex tasks that require their advanced skills.
Choice D reason:
Developing a teaching plan for a client newly diagnosed with Type II Diabetes is a task that should not be delegated to an LPN. This task requires comprehensive knowledge of diabetes management, patient education, and individualized care planning, which are within the RN’s scope of practice. The RN should develop the teaching plan and may involve the LPN in reinforcing the education.
Choice E reason:
Providing oral care to an unconscious client is a task that can be delegated to an experienced LPN. Oral care is essential for preventing infections and maintaining hygiene, and LPNs are trained to perform this care safely and effectively.
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Correct Answer is D
Explanation
Choice A reason:
Blunt force trauma refers to injuries caused by impact with a blunt object, resulting in contusions, abrasions, lacerations, or fractures. While blunt force trauma can occur in explosions, it is typically associated with tertiary blast injuries, where the victim is thrown against a solid object. Secondary injuries from high-order explosives are more specifically related to penetrating injuries caused by flying debris and shrapnel.
Choice B reason:
Hollow organ damage is a type of primary blast injury caused by the overpressure wave from an explosion. This wave can cause significant damage to gas-filled organs such as the lungs, intestines, and ears. However, secondary injuries are not typically characterized by hollow organ damage. Secondary injuries are more commonly associated with penetrating trauma from debris and shrapnel.
Choice C reason:
Post-trauma stress disorder (PTSD) is a psychological condition that can develop after experiencing or witnessing a traumatic event. While PTSD is a serious and common consequence of exposure to explosions and other traumatic events, it is not classified as a secondary injury. Secondary injuries refer to physical injuries caused by flying debris and shrapnel, not psychological conditions.
Choice D reason:
Penetrating injuries are the hallmark of secondary blast injuries. These injuries occur when fragments from the explosive device or surrounding materials are propelled at high velocity, causing wounds that penetrate the skin and underlying tissues. These injuries can be severe and life-threatening, requiring immediate medical attention. The nurse should anticipate and be prepared to manage penetrating injuries in clients exposed to high-order explosives.
Correct Answer is B
Explanation
Choice A reason:
“It is a test that determines which activities you feel most comfortable performing” is not entirely accurate. While comfort with activities may be assessed, the primary goal of a functional assessment is to evaluate the client’s ability to perform activities of daily living (ADLs) and instrumental activities of daily living (IADLs).
Choice B reason:
“It is a tool that is used to determine your maximum level of self-sufficiency.” This response accurately reflects the purpose of a functional assessment. The assessment evaluates the client’s ability to perform ADLs and IADLs independently, which helps determine the level of assistance they may need.
Choice C reason:
“It is a tool that is used to assess what services you will need a home health aide to perform for you” is partially correct but not comprehensive. While the assessment can help identify the need for home health aide services, its primary purpose is to evaluate overall self-sufficiency and functional status.
Choice D reason:
“It is a tool used by insurance companies to determine qualifications for medical reimbursement” is not the primary purpose of a functional assessment. Although the results may be used for insurance purposes, the main goal is to assess the client’s functional abilities and needs.