NCLEX-PN Test #16 2 Flashcards

The PN is working with a nursing assistant (NA). Which task is appropriate to delegate to the NA?

Answer: Measure and record intake and output for a stable client

Measuring and recording intake/output is an appropriate task for a nursing assistant as it requires data collection for a stable client but does not require nursing assessment or clinical judgment. Assessment, medication administration (in most states), and evaluation of clinical responses are within the nurse's scope and cannot be delegated to an NA.

A charge nurse asks the PN to float to the ICU to care for a critically ill ventilated client. The PN has no ICU experience. What is the appropriate response?

Answer: Communicate your specific competency limitations to the charge nurse and request a buddy assignment or limited scope within your competence

Nurses have a professional and legal obligation to practice within their scope of competence. The appropriate response is to communicate specific limitations (not blanket refusal), offer to perform tasks within competence (standard assessments, oral medications), and request a buddy system for complex tasks beyond training. This protects patient safety and meets professional standards.

The PN receives a change-of-shift report. Which client should the nurse assess first after receiving report?

Answer: A client who just returned from dialysis with BP of 88/52 and dizziness

Hypotension (BP 88/52) with dizziness in a post-dialysis client is a priority emergency — indicating significant fluid removal, dysrhythmia, or cardiovascular compromise. This requires immediate assessment. The other clients have scheduled or non-urgent needs. Using the ABC and Maslow frameworks: circulation is threatened in the post-dialysis client.

Which action is within the scope of practice for a Licensed Practical Nurse (PN/LPN) in most states?

Answer: Administering prescribed medications and documenting the client's response

LPN/PN scope of practice includes: administering medications (oral, IM, subcutaneous, topical — IV varies by state), collecting assessment data, performing routine treatments, and documenting. Initial comprehensive assessment, independent care plan development, and diagnosis are within the RN scope. LPNs contribute to care planning under RN supervision.

The PN overhears a colleague telling a client's family confidential information in the hospital hallway. What is the most appropriate action?

Answer: Report the observation to the nurse manager and document the incident per facility policy

HIPAA violations in the workplace must be reported through the appropriate channels — typically the nurse manager or compliance officer, followed by documentation per facility policy. Nurses have a professional obligation to maintain client confidentiality and to report breaches. Hallway conversations about clients violate privacy even if inadvertent.

After administering a narcotic analgesic, the PN notes the client's respiratory rate has dropped to 9 breaths per minute. What is the priority action?

Answer: Stimulate the client by shaking their shoulder and calling their name, then administer naloxone as ordered and notify the provider

Respiratory rate < 12/min after opioid administration indicates respiratory depression — a medical emergency. Immediate actions: attempt to arouse the client, administer naloxone (Narcan) as ordered, call for help, maintain airway, and monitor closely. Naloxone reverses opioid-induced respiratory depression within minutes but has a shorter half-life than most opioids, requiring re-dosing.