NCLEX Prep Questions and answers.

NCLEX Prep Questions and answers.DELEGATION ... The team is providing emergency care to a client who received an excessive dose of opioid pain medication. Which task is best to assign to the LPN/LVN? 1. Calling the health care provider (HCP) to report SBAR (situation, background, assessment, recommendation) 2. Giving naloxone and evaluating response to therapy 3. Monitoring the respiratory status for the first 30 minutes 4. Applying oxygen per nasal cannula as ordered 4. Applying oxygen per nasal cannula as ordered Rationale: The LPN/LVN is well trained to administer 02 via nasal cannula. This client is considered unstable; therefore, the RN should take responsibility for administering drugs and monitoring responses to therapy, which include the effects on the respiratory system. The RN should also take responsibility to communicate with the HCP for ongoing treatment and therapy. 00:25 01:22 In the care of a patient with neutropenia, what tasks should the nurse instruct unlicensed assistive personnel (UAP) to perform? Select all that apply. 1. Taking vital signs every 4 hours 2. Reporting temperature of more than 100.4°F (38°C) 3. Assessing for sore throat, cough, or burning with urination 4. Gathering the supplies to prepare the room for protective isolation 5. Reporting superinfections, such as candidiasis 6. Practicing good hand-washing technique 1. Taking vital signs every 4 hours 2. Reporting temperature of more than 100.4°F (38°C) 4. Gathering the supplies to prepare the room for protective isolation 6. Practicing good hand-washing technique Rationale: Measuring vital signs and reporting on specific parameters, practicing good hand washing, and gathering equipment are within the scope of duties for a UAP. Assessing for symptoms of infections and superinfections is the responsibility of the RN. Which tasks are appropriate to assign to an LPN/LVN who is functioning under the supervision of an RN? Select all that apply. 1. Administering sulfacetamide sodium 10% to a child with conjunctivitis 2. Reviewing hand-washing and hygiene practices with clients who have eye infections 3. Showing clients how to gently cleanse eyelid margins to remove crusting 4. Assessing nutritional factors for a client with age-related macular degeneration 5. Reviewing the health history of a client to identify risk for ocular manifestations 6. Performing a routine check of a client's visual acuity using the Snellen eye chart 1. Administering sulfacetamide sodium 10% to a child with conjunctivitis 2. Reviewing hand-washing and hygiene practices with clients who have eye infections 3. Showing clients how to gently cleanse eyelid margins to remove crusting 6. Performing a routine check of a client's visual acuity using the Snellen eye chart Rationale: Administering medications, reviewing and demonstrating standard procedures, and performing standardized assessments with predictable outcomes in noncomplex cases are within the scope of the LPN/LVN. Assessing for systemic manifestations and behaviors, risk factors, and nutritional factors is the responsibility of the RN. After a client has a seizure, which action can the nurse delegate to the unlicensed assistive personnel (UAP)? 1. Documenting the seizure 2. Performing neurologic checks 3. Checking the client's vital signs 4. Restraining the client for protection 3. Checking the client's vital signs Rationale: Measurement of vital signs is within the education and scope of practice of UAPs. The nurse should perform neurologic checks and document the seizure. Clients with seizures should not be restrained; however, the nurse may guide the client's movements, if necessary, to prevent injury. The nurse is working in a hospice facility for patients with acquired immunodeficiency syndrome (AIDS). The facility is staffed with LPNs/LVNs and unlicensed assistive personnel (UAP). Which action will the nurse assign to the LPN/LVN? 1. Assessing patients' nutritional needs and individualizing diet plans to improve nutrition 2. Collecting data about the patients' responses to medications used for pain and anorexia 3. Developing UAP training programs about how to lower the risk for spreading infections 4. Assisting patients with personal hygiene and other activities of daily living as needed 2. Collecting data about the patients' responses to medications used for pain and anorexia Rationale: The collection of data used to evaluate the therapeutic and adverse effects of medications is included in LPN/LVN education and scope of practice. Assessment, planning, and developing teaching programs are more complex skills that require RN education. Assistance with hygiene and activities of daily living should be delegated to the UAP. The client has fluid volume deficit related to excessive fluid loss. Which action related to fluid management should be delegated by the RN to unlicensed assistive personnel (UAP)? 1. Administering IV fluids as prescribed by the physician 2. Providing straws and offering fluids between meals 3. Developing a plan for added fluid intake over 24 hours 4. Teaching family members to assist the client with fluid intake 2. Providing straws and offering fluids between meals Rationale: UAPs can reinforce additional fluid intake when it is part of the care plan. Administering IV fluids, developing plans, and teaching families require additional education and skills that are within the scope of practice of an RN. Test Taking Tip: The nurse must be familiar with the scope of practice for UAPs before delegating client care tasks. UAP scope of practice includes checking vital signs, tasks associated with activities of daily living such as bathing and oral care, feeding, and recording intake and output. UAPs can provide items such as drinking straws and can encourage and remind clients about instructions from the nurse such as increasing fluid intake. 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 LPN/LVN being supervised by a nurse? Select all that apply. 1. Reminding the client to avoid commercial mouthwashes 2. Encouraging mouth rinsing 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 consult to increase fluids on meal trays 1. Reminding the client to avoid commercial mouthwashes 2. Encouraging mouth rinsing with warm saline 4. Observing the lips, tongue, and mucous membranes 5. Providing mouth care every 2 hours while the client is awake Rationale: The LPN/LVN scope of practice and educational preparation includes oral care and routine observation. State practice acts vary as to whether LPNs/LVNs are permitted to perform assessment. The client should be reminded to avoid most commercial mouthwashes, which contain agents such as alcohol. To assess skin turgor in an older adult, skin tenting is best checked by pinching the skin over the sternum or on the forehead rather than the back of the hand. With aging, the skin loses elasticity and tents on hands and arms even when the adult is well hydrated. Initiating a dietary consult is within the purview of the RN or health care provider. A client with a vancomycin-resistant enterococcus (VRE) infection is admitted to the medical unit. Which action can be delegated to the unlicensed assistive personnel (UAP) who is assisting with the client's care? 1. Teaching the client and family members about means to prevent transmission of VRE 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 culture and sensitivity tests 3. Implementing contact precautions when providing care for the client Rationale: All hospital personnel who care for the client are responsible for correct implementation of contact precautions. The other actions should be carried out by licensed nurses, whose education covers monitoring of laboratory results, client teaching, and communication with other departments about essential client data. The nurse is caring for a client who has been admitted to the hospital with a leg ulcer that is infected with vancomycin-resistant Staphylococcus aureus (VRSA). Which nursing action can be assigned to an LPN/LVN? 1. Planning ways to improve the client's oral protein 2. Teaching the client about home care of the leg ulcer 3. Obtaining wound cultures during dressing changes 4. Assessing the risk for further skin breakdown 3. Obtaining wound cultures during dressing changes Rationale: LPN/LVN education and scope of practice include performing dressing changes and obtaining specimens for wound culture. Teaching, assessment, and planning of care are complex actions that should be carried out by the RN. Which infection control activity should the charge nurse delegate to an experienced unlicensed assistive personnel (UAP)? 1. Screening clients for upper respiratory tract symptoms 2. Asking clients about the use of immunosuppressant medications 3. Demonstrating correct hand washing to the clients' visitors 4. Disinfecting blood pressure cuffs after clients are discharged 4. Disinfecting blood pressure cuffs after clients are discharged Rationale: The UAP can follow agency policy to disinfect items that come in contact with intact skin (e.g., blood pressure cuffs) by cleaning with chemicals such as alcohol. Teaching and assessment for upper respiratory tract symptoms or use of immunosuppressants require more education and a broader scope of practice, and those tasks should be performed by licensed nurses. The nurse is preparing to admit a client with a seizure disorder. Which action can be assigned to an LPN/LVN? 1. Completing the admission assessment 2. Setting up oxygen and suction equipment 3. Placing a padded tongue blade at the bedside 4. Padding the side rails before the client arrives 2. Setting up oxygen and suction equipment Rationale: The LPN/LVN scope of practice includes setting up the equipment for oxygen and suctioning. The RN should perform the complete initial assessment. Controversy exists as to whether padded side rails actually provide safety, and their use may embarrass the client and family. Tongue blades should not be at the bedside and should never be inserted into the client's mouth after a seizure begins.