3. The nursing care plan for the client with dehydration includesinterventions for oral health. Which interventions are within thescope of practice for an LPN/ LVN being supervised by anurse? (Select all that apply.) 1. Reminding the client to avoid commercial mouthwashes 2. Encouraging mouth rinsing with warm saline 3. Observing the lips, tongue, and mucous membranes 4. Providing mouth care every 2 hours while the client is awake 5. Seeking a dietary consult to increase fluids on meal trays 3. Ans: 1, 2, 3, 4 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 alcohol, a drying agent. Initiating a dietary consult is within the purview of the RN or physician. Focus: Delegation, supervision LaCharity, Linda A.; Kumagai, Candice K.; Bartz, Barbara (2013-11-22). Prioritization, Delegation, and Assignment: Practice Excercises for the NCLEX Exam (p. 172). Elsevier Health Sciences. Kindle Edition. 3. The UAP tells you that a patient who is receivingoxygen at a flow rate of 6 L/ min by nasal cannula isreporting nasal passage discomfort. Whatintervention should you suggest to improve thepatient's comfort for this problem? 1. Humidify the patient's oxygen. 2. Use a simple face mask instead of a nasal cannula. 3. Provide the patient with an extra pillow. 4. Have the patient sit up in a chair at the bedside. 3. Ans: 1 When the oxygen flow rate is higher than 4 L/ min, the mucous membranes can be dried out. The best treatment is to add humidification to the oxygen delivery system. Applying water-soluble jelly to the nares can also help decrease mucosal irritation. None of the other options will treat the problem. Focus: Prioritization LaCharity, Linda A.; Kumagai, Candice K.; Bartz, Barbara (2013- 11-22). Prioritization, Delegation, and Assignment: Practice Excercises for the NCLEX Exam (p. 175). Elsevier Health Sciences. Kindle Edition. 3. When a primary survey of a trauma clientis conducted, what is considered one of thepriority actions? 1. Obtain a complete set ofvital sign measurements. 2. Palpate and auscultate the abdomen. 3. Perform a brief neurologic assessment. 4. Check the pulse oximetry reading. 3. Ans: 3 A brief neurologic assessment to determine level of consciousness and pupil reaction is part of the primary survey. Measuring vital signs, assessing the abdomen, and checking pulse oximetry readings are considered part of the secondary survey. Focus: Prioritization LaCharity, Linda A.; Kumagai, Candice K.; Bartz, Barbara (2013- 11-22). Prioritization, Delegation, and Assignment: Practice Excercises for the NCLEX Exam (p. 204). Elsevier Health Sciences. Kindle Edition.
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