Difficulty: Medium
Average Score: 75%
Simulated
Passage / Scenario
The following scenario applies to the next 1 itemsThe charge nurse in the medical-surgical unit is preparing the assignment for the next shift.
ÔÇó Client One
ÔÇó 63-year-old male admitted three days ago for community-acquired pneumonia.
ÔÇó Intravenous (IV) antibiotics stopped and were switched to oral. Plan is for discharge in one day. Family is at the bedside.
ÔÇó Current medications: azithromycin, levofloxacin, warfarin, atorvastatin, acetaminophen, and albuterol via nebulizer.
ÔÇó Medical history: mitral valve replacement, venous thromboembolism, and hyperlipidemia.
ÔÇó Vital signs: T 101┬░ F (39.7┬░ C), P 72, RR 18, BP 130/86, pulse oximetry reading 95% on room air.
ÔÇó Client Two
ÔÇó 55-year-old female admitted two days ago with aplastic anemia.
ÔÇó Received two units of packed red blood cells yesterday.
ÔÇó Client is scheduled to receive two units of platelets. She developed epistaxis and vaginal bleeding in the last hour.
ÔÇó Current medications: multivitamin and lisinopril.
ÔÇó Medical history: aplastic anemia and hypertension.
ÔÇó Vital signs: T 98.6┬░ÔÇëF (37┬░ÔÇëC), P 88, RR 15, BP 111/76, pulse oximetry reading 96% on room air.
ÔÇó Client Three
ÔÇó 23-year-old male admitted four days ago with chest trauma caused by a stab wound.
ÔÇó Transferred to the medical-surgical unit yesterday. Chest tube was discontinued yesterday.
ÔÇó Client is to ambulate every four hours (while awake). Has constipation and needs an enema.
ÔÇó Current medications: oxycodone-acetaminophen, docusate, and regular insulin sliding scale.
ÔÇó Medical history: diabetes mellitus (type one).
ÔÇó Vital signs: T 98┬░ÔÇëF (36.4┬░ÔÇëC), P 80, RR 16, BP 119/86, pulse oximetry reading 96% on room air.
ÔÇó Client Four
ÔÇó 52-year-old female admitted two hours ago following total abdominal hysterectomy.
ÔÇó Occasional nausea. Hypoactive bowel sounds in all quadrants. Has an indwelling urinary catheter connected to drainage bag.
ÔÇó Current medications: hydrocodone-acetaminophen, docusate, and ondansetron.
ÔÇó Medical history: cervical cancer.
ÔÇó Vital signs: T 98┬░ÔÇëF (36.4┬░ÔÇëC), P 70, RR 16, BP 125/88, pulse oximetry reading 95% on room air
ÔÇó Client Five
ÔÇó 45-year-old male admitted four hours ago with new onset atrial fibrillation.
ÔÇó Irregular pulse. Had two episodes of syncope in the emergency department.
ÔÇó Current medications: continuous infusion of diltiazem.
ÔÇó Medical history: hypertension and congestive heart failure.
ÔÇó Vital signs: T 98┬░ÔÇëF (36.4┬░ÔÇëC), P 101, RR 19, BP 137/90, pulse oximetry reading 96% on room air
ÔÇó Client Six
ÔÇó 77-year-old male admitted one day ago with cystitis.
ÔÇó Receives medications and feedings through percutaneous endoscopic gastrostomy (PEG). Requires daily dressing changes for sacral pressure ulcer.
ÔÇó Current medications: citalopram, esomeprazole, atenolol, ciprofloxacin.
ÔÇó Medical history: hypertension, anxiety, acid reflux.
ÔÇó Vital signs: T 98.2┬░ÔÇëF (36.8┬░ÔÇëC), P 82, RR 15, BP 133/88, pulse oximetry reading 95% on room air
ÔÇó Client Seven
ÔÇó 72-year-old female admitted two days ago with cystitis and improving altered mental status.
ÔÇó Receiving intermittent intravenous piggyback antibiotics.
ÔÇó Current medications: rivaroxaban, diltiazem, and captopril.
ÔÇó Medical history: atrial fibrillation and hypertension.
ÔÇó Vital signs: T 98.9┬░ÔÇëF (37.2┬░ÔÇëC), P 67, RR 16, BP 143/85, pulse oximetry reading 96% on room air
The charge nurse is determining which client should be assigned to the licensed practical/vocational nurse (LPN/VN) or registered nurse (RN).Click to specify if the client should be assigned to the LPN/VN or RN.
Rationale
Client One
This client is stable, with IV antibiotics discontinued and switched to oral. The LPN can manage routine medication administration, monitor for any signs of infection recurrence, and provide discharge education under the supervision of an RN.
Client Three
The client is stable and primarily requires routine care, such as scheduled ambulation and assistance with bowel management (enema administration). The LPN is qualified to administer medications and monitor for any changes in respiratory status following chest trauma.
Client Six
This client is stable and requires PEG tube feedings, medication administration, and daily dressing changes for a sacral pressure ulcer. These tasks fall within the LPNÔÇÖs scope of practice, as long as the RN remains available for more complex assessments if needed.
Client Seven
The client is showing improvement, is hemodynamically stable, and requires intermittent IV piggyback antibiotics. LPNs are trained to administer IV piggyback medications and monitor for adverse effects. Routine vital sign monitoring and medication administration are appropriate for LPN delegation.
Clients that should be assigned to the RN
Client Two
This client presents an increased risk of hemodynamic instability due to new-onset bleeding (epistaxis and vaginal bleeding), requiring close assessment and intervention. The RN is needed to evaluate the severity of bleeding, administer platelet transfusions, and monitor for transfusion reactions or worsening anemia.
Client Four
Postoperative clients are at risk for complications such as hemorrhage, infection, and ileus. The RN is required to perform a comprehensive assessment, evaluate bowel function, manage nausea, and ensure the catheter remains patent without signs of infection.
Client Five
This client is on continuous IV diltiazem, which requires ongoing cardiac monitoring and dosage adjustments based on response. The clientÔÇÖs history of syncope raises concerns for hemodynamic instability, which necessitates RN oversight for timely intervention if deterioration occurs.
This client is stable, with IV antibiotics discontinued and switched to oral. The LPN can manage routine medication administration, monitor for any signs of infection recurrence, and provide discharge education under the supervision of an RN.
Client Three
The client is stable and primarily requires routine care, such as scheduled ambulation and assistance with bowel management (enema administration). The LPN is qualified to administer medications and monitor for any changes in respiratory status following chest trauma.
Client Six
This client is stable and requires PEG tube feedings, medication administration, and daily dressing changes for a sacral pressure ulcer. These tasks fall within the LPNÔÇÖs scope of practice, as long as the RN remains available for more complex assessments if needed.
Client Seven
The client is showing improvement, is hemodynamically stable, and requires intermittent IV piggyback antibiotics. LPNs are trained to administer IV piggyback medications and monitor for adverse effects. Routine vital sign monitoring and medication administration are appropriate for LPN delegation.
Clients that should be assigned to the RN
Client Two
This client presents an increased risk of hemodynamic instability due to new-onset bleeding (epistaxis and vaginal bleeding), requiring close assessment and intervention. The RN is needed to evaluate the severity of bleeding, administer platelet transfusions, and monitor for transfusion reactions or worsening anemia.
Client Four
Postoperative clients are at risk for complications such as hemorrhage, infection, and ileus. The RN is required to perform a comprehensive assessment, evaluate bowel function, manage nausea, and ensure the catheter remains patent without signs of infection.
Client Five
This client is on continuous IV diltiazem, which requires ongoing cardiac monitoring and dosage adjustments based on response. The clientÔÇÖs history of syncope raises concerns for hemodynamic instability, which necessitates RN oversight for timely intervention if deterioration occurs.