Which nursing interventions included in the care of a mechanically ventilated patient with acute respiratory failure can the registered nurse (RN) delegate to an experienced licensed practical/vocational nurse (LPN/LVN) working in the intensive care unit?
a. Assess breath sounds every hour.
b. Monitor central venous pressures.
c. Place patient in the prone position.
d. Insert an indwelling urinary catheter.
ANS: D
Insertion of indwelling urinary catheters is included in LPN/LVN education and scope of practice and can be safely delegated to an LPN/LVN who is experienced in caring for critically ill patients. Placing a patient who is on a ventilator in the prone position requires multiple staff, and should be supervised by an RN. Assessment of breath sounds and obtaining central venous pressures require advanced assessment skills and should be done by the RN caring for a critically ill patient.
You might also like to view...
A woman who is a Jehovah's Witness returns for a second prenatal visit and is discussing her plan of care with the nurse. The patient has returned a signed form in which she refuses all blood products. What action by the nurse is best?
A. Advise the woman of potential complications. B. Inform the health-care provider of her choice. C. Place the signed form on the patient's chart. D. Refer the woman to a tertiary birthing center.
The nurse is performing a skin assessment on an African American client and notes an elevated, irregular band of jagged tissue on the client's left arm
The client states, "I had a burn here a long time ago, but it seemed to keep on getting bigger.". The nurse would correctly document this finding in which of the following ways? 1. Ulcer 2. Keloid 3. Fissure 4. Scar
A patient is being moved into a dangling position before ambulating. To decrease the chance of orthostatic hypotension, what activity can the patient do?
a. Sit on the side of the bed for a minute be-fore standing up. b. Take several deep breaths while moving into the dangling position. c. Push up from the bed into the dangling position on the side of the bed. d. Stretch all of the muscles in the body.
A nurse is reviewing a patient's most recent blood count and notes that the patient has a hemoglobin of 9.6 gm/dL and a hematocrit of 33%. The nurse will notify the provider and will expect initial treatment to include:
a. determining the cause of the anemia. b. giving intravenous iron dextran. c. giving oral carbonyl iron (Feosol). d. teaching about dietary iron.