1. You are assessing a long-term-care client with a history ofbenign prostatic hyperplasia (BPH). Which information willrequire the most immediate action? 1. The client states that he always has trouble starting his urinary stream. 2. The chart shows an elevated level of prostate-specific antigen. 3. The bladder is palpable above the symphysis pubis and the client is restless. 4. The client says he has not voided since having a glass of juice 4 hours ago. 1. Ans: 3 A palpable bladder and restlessness are indicators of urinary retention, which would require action (such as insertion of a catheter) to empty the bladder. The other data would be consistent with the client's diagnosis of BPH. More detailed assessment may be indicated, but no immediate action is required. Focus: Prioritization 1. You are caring for a client who has just had a squamous cellcarcinoma removed from the face. Which activity can youdelegate to an experienced LPN/ LVN? 1. Teaching the client about risk factors for squamous cell carcinoma 2. Showing the client how to care for the surgical site at home 3. Monitoring the surgical site for swelling, bleeding, or pain 4. Discussing the reasons for avoiding aspirin use for a week after surgery 1. Ans: 3 An LPN/ LVN who is experienced in working with postoperative clients will know how to monitor for pain, bleeding, or swelling and will notify the supervising RN. Client teaching requires more education and a broader scope of practice and is appropriate for RN staff members. Focus: Delegation LaCharity, Linda A.; Kumagai, Candice K.; Bartz, Barbara (2013- 11-22). Prioritization, Delegation, and Assignment: Practice Excercises for the NCLEX Exam (p. 193). Elsevier Health Sciences. Kindle Edition. 1. You are caring for a patient withesophageal cancer. Which task could bedelegated to a UAP? 1. Assisting the patient with oral hygiene 2. Observing the patient's response to feedings 3. Facilitating expression of grief or anxiety 4. Initiating daily weighings 1. Ans: 1 Oral hygiene is within the scope of duties of the UAP. It is the responsibility of the nurse to observe response to treatments and to help the patient deal with loss or anxiety. The UAP can be directed to weigh the patient but should not be expected to know when to initiate that measurement. Focus: Delegation LaCharity, Linda A.; Kumagai, Candice K.; Bartz, Barbara (2013- 11-22). Prioritization, Delegation, and Assignment: Practice Excercises for the NCLEX Exam (p. 168). Elsevier Health Sciences. Kindle Edition.
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