Fluid & Electrolyte Imbalance
Pt with fluid volume deficit related to excessive fluid loss. Which action related to fluid management should be delegated by the RN to the UAP?
1. Administering IV fluids as ordered
2. Providing straws and offering fluids between meals
3. Developing a plan of care with the RN
4. Teaching family members how to assist the client with fluid intake
2. Providing straws and offering fluids between meals.
Rationale: UAPs can encourage additional fluid intake.
A client with a vancomycin resistant enterococcus (VRE) infection is admitted to the medical unit. Which action can be delegated to the UAP?
1. Teaching the client and family members about means to prevent transmission of VREs
2. Communicating with other departments when the client is transported for ordered tests
3. Implementing contact precautions when providing care for the client
4. Monitoring the results of ordered laboratory cultures and sensitivity tests
3. Implementing contact precautions when providing care for the patient.
Rationale: UAPs should adhere to safety precautions
Which pediatric pain patient should be assigned to a newly graduated nurse?
1. An adolescent who as sickle cell disease and was recently weaned from morphine delivered via a PCA analgesia device to an oral analgesic; he has been consistently asking for an increased dose
2. A child who needs premedication before reduction of a fracture; the child has been crying and does not want to be touched
3. A child who is receiving palliative end of life care; the child has been receiving opioids mourned the clock to relieve suffering, but there is a progressive decrease in alertness and responsiveness
4. A child who has a chronic pain and whose medication and nonpharmacologic regimen has recently been changed; the mother is anxious to see if the new regiment is successful
2. A child who needs premedication before reduction of a fracture; the child has been crying and does not want to be touched
Which patient would the Charge Nurse assign to the experienced RN?
1. Client in MVC with multiple injuries
2. Pt. with chronic back pain
3. Cholecystectomy pt. post-op day two
4. Pt. experiencing alcohol withdrawal who is diaphoretic and anxious
1. Client in MVC with multiple injuries
Rationale:Unstable vs. Stable
The nursing care plan for an older client with dehydration includes interventions for oral health. Which interventions are within the scope of practice for an LON being surpervised by the nurse?
1. Reminding the client to avoid commercial mouthwashes
2. Encouraging the mouth ringing with warm saline
3. Assess skin turgor by pinching the skin over the back of the hand
4. Observing the lips tongue and mucous membranes
5. Providing mouth care every 2 hours while the client is awake
6. Seeking a dietary consults to increase fluids on meal trays
1,2,4,5
A client who has frequent watery stools and a possible C.diff infection is hospitalized with dehydration. Which nursing action should be assigned to the LPN?
1. Performing ongoing assessments to determine the clients hydrations status
2. Explaining the purpose of ordered stool cultures to the client and family
3. Administering the prescribed metronidazole 500mg PO to the client
4. Reviewing the clients medical history for any risk factors for diarrhea
3. Administering the prescribed metronidazole 500mg PO to the client
An 18-month-old child has oral mucositis secondary to chemotherapy. Which task should the nurse delegate to the UAP?
1. Reporting evidence of severe mucosal ulceration
2. Assisting the child in swishing and spitting mouthwash
3. Assessing the child's ability and willingness to drink through a straw
4. Feeding the child a bland, moist, soft diet
4. Feeding the child a bland, moist, soft diet.
Rationale: Within scope. 18-month-old can't swish and spit.
In the care of a patient with pain and discomfort, which task is MOST appropriate to assign to he UAP?
1. Assisting client with sitz bath
2. Monitoring for signs of discomfort while ambulating
3. Coaching the client to deep breath during painful procedure
4. Evaluating relief after applying cold compress
1. Assisting the client for sitz bath
Rationale: UAP can assist with hygiene.
The charade nursing is assigned to the car of a client with acute kidney failure and hypernatremia to a new grad RN. Whish actions can the new graduate RN delegate to the UAP?
1. Oral care every 3-4 hours
2. Monitoring for indications of dehydration
3. Administering 0.45% saline by IV
4. Recording urine output when client voids
5. Assessing daily weights for trends
6. Help the client change position every 2 hours
1,4,6
The nurse is caring for a confused and agitated client who has a wrist restraints in place on both arms. Which action included in the client plan of care can be assigned to an LPN?
1. Determining whether the client's mental status justifies the continued use of restraints
2. Undoing and retying the restraints to improve client comfort
3. Reporting the clients status and continued need for restraints to the health care provider.
4. Explaining the purpose of the restraints to the client's family members
2. Undoing and retying the restraints to improve client comfort
The pediatric charge nurse is making patient assignments for the evening shift. Which patient is most appropriate to assign to an experienced LPN?
1. A 1-year-old patient with severe combined immunodeficiency disease who is scheduled to receive chemotherapy
2. A 2-year-old patient with Wiskott-Aldrich syndrome who has orders for a platelet transfusion
3. A 3-year-old patient who has chronic graft-versus-host and is incontinent of loose stools
4. A 6-year-old patient who received chemotherapy 1 week ago and is admitted with increasing letherary and a temp of 101F
3. 3-year-old patient who has chronic graft-versus-host and is incontinent of loose stools
Rationale: Chronic vs Stable
Team is providing emergency care to a client who received and excessive dose of opioid pain medication. Which task is bets to assign to the LPN?
1. Giving SBAR to PCP
2. Giving naloxone and evaluating response
3. Monitoring respiratory status for first thirty minutes
4. Administering O2 as ordered
4. Administering O2 as ordered.
Rationale:Within scope of practice