Rationale:

A. "The client works in the hospital radiology department." This information is important for understanding the client's background but does not indicate a need for total care by the nurse.

B. "The client discussed having prior thoughts of suicide." This statement indicates a high-risk situation requiring close monitoring and direct care by the nurse, rather than delegating tasks to an AP. The client's safety and mental health status necessitate the nurse's full attention.

C. "The client's blood pressure and pulse have been fluctuating throughout the day." While this information suggests the need for monitoring, it doesn't necessarily preclude the AP from assisting with certain tasks under the nurse's supervision.

D. "The client's family members have been present most of the day." This statement provides context but does not indicate a need for total care by the nurse.

Rationale:

A. Reporting the observation to the nurse caring for that client is important but not the immediate priority.

B. Informing the nursing supervisor is necessary but should be done after assessing the situation directly.

C. Approaching the man and asking why he is making copies is the most immediate and direct action. It allows the nurse to assess the situation and determine if the man has legitimate access to the client's medical record or if further action is needed.

D. Notifying hospital security may be necessary if the man’s actions are unauthorized, but the first step is to gather more information.

Rationale:

A. Check the position of a client in soft wrist restraints is appropriate for an AP as it involves routine monitoring and ensuring the client's safety.

B. Accompany a client who has depression to occupational therapy is a task that can be assigned to an AP, as it involves providing support and ensuring the client's safe arrival to therapy.

C. Set limits with a client who has mania is not appropriate for an AP, as this involves therapeutic communication and behavior management, which requires nursing judgment.

D. Sit with a client who has alcohol use disorder and whose last drink was five days ago can be assigned to an AP as it involves providing a supportive presence and monitoring, but the nurse should assess for withdrawal symptoms.

E. Assess a client who has hypomania for exhaustion is a nursing responsibility that involves evaluation and judgment, making it inappropriate to delegate to an AP.

Rationale:

A. Ambulate an older adult client who has hypertension is a task that an AP can perform, provided the client is stable and has been assessed by the nurse.

B. Provide discharge instructions for a client who has a new skin graft is a task that requires nursing judgment and cannot be delegated to an AP.

C. Check a blood product with another nurse prior to administration is a nursing responsibility that requires verification by licensed personnel and cannot be delegated to an AP.

D. Weigh a client who has heart failure is appropriate for an AP, as it involves routine measurement that can be delegated.

E. Perform an admission assessment on a client is a nursing responsibility and cannot be delegated to an AP.

Rationale:

A. Dilated pupils are typically associated with stimulant use, not opioids.

B. Euphoria is a common effect of opioid use and can indicate misuse or diversion of these medications.

C. Rhinorrhea is usually associated with withdrawal from opioids rather than their use.

D. Hallucinations can occur with certain drugs but are less commonly associated with opioid use compared to euphoria.

Rationale:

A. The client should sign the informed consent if they are alert, oriented, and capable of making decisions. The client's ability to understand the procedure and its implications is key to valid informed consent.

B. The client's son, who has a durable power of attorney would only sign the consent if the client were not competent or unable to understand the procedure, which is not the case here.

C. The client's partner may be involved in the decision-making process but does not have the legal authority to sign the consent unless designated as a legal representative.

D. The client's daughter, who is the primary caregiver would also not have the legal authority to sign the consent unless she holds a durable power of attorney or the client is deemed incapable of giving consent.

Rationale:

A. While the client's temperature is not extremely high, it is elevated and persistent. Requesting an antipyretic or further evaluation may be warranted to prevent potential complications.

B. Insertion of NG tube for decompression is not necessary as the client is passing flatus and has bowel sounds in all quadrants, indicating normal gastrointestinal function.

C. Oxygen 2 to 4 L/min via nasal cannula is not necessary since the client's SpO2 levels are within normal range on room air.

D. The client's urinary output is adequate (400 mL over 6 hours), so a catheter is not required at this time.

E. The lack of drainage from the wound drain could indicate a problem that requires immediate attention. This could prevent complications like infection or fluid accumulation.

Rationale:

A. A client who has Guillain-Barre syndrome requires close monitoring and specialized care due to progressive weakness and potential respiratory issues. This client's care may involve more complex needs that are beyond the AP's scope.

B. A client who has a lumbosacral spinal tumor is likely to have fewer immediate needs related to eating assistance, making this task appropriate to delegate to the AP. The client’s primary concern may be mobility or pain management, but meal assistance is a routine task.

C. A client who has systemic sclerosis may have issues with gastrointestinal motility and swallowing, requiring more careful feeding assistance and monitoring, which should be performed by the nurse.

D. A client who has amyotrophic lateral sclerosis (ALS) requires specialized care for swallowing difficulties and respiratory issues, making it inappropriate to delegate meal assistance to the AP.

Rationale:

A. A young adult client admitted for acute glomerulonephritis following a viral infection does not indicate a mandatory report situation.

B. A dependent adult admitted for the treatment of a spiral fracture suggests potential abuse or neglect. As mandated reporters, nurses are required to report suspicions of abuse or neglect to the appropriate authorities.

C. A young adult client admitted for asthma and has track marks that may indicate IV drug abuse does not necessarily require mandatory reporting unless there is evidence of abuse or harm that needs to be reported.

D. An emancipated minor who has acute appendicitis and wants to leave the facility without treatment may raise concerns about the minor's capacity to make decisions, but it does not automatically necessitate reporting to an outside agency.

Rationale:

A. Informing the staff member of her appraisal time for that day prior to change-of-shift report is not ideal as it may disrupt the shift handover process.

B. Scheduling the appraisal interview as early in the shift as possible might not be feasible or considerate, especially if it impacts patient care or the staff member's workflow.

C. Providing the staff member with a copy of the appraisal form in advance is best practice as it allows the staff member to prepare for the discussion and address any concerns or achievements.

D. Providing a chair directly across the desk for the staff member to sit in is not as important as preparing the staff member by sharing the appraisal criteria in advance.

Rationale:

A. A client who was administered erythromycin for acute glomerulonephritis and reports reddish-brown urinary output requires assessment for possible drug reaction or hematuria, but this may not be immediately life-threatening compared to hypoglycemia.

B. A client who was administered glipizide for type 2 diabetes mellitus and has a blood glucose of 68 mg/dL is at risk for hypoglycemia, which requires prompt assessment and intervention to prevent severe complications.

C. A client who was administered adalimumab for Crohn's disease, has a serum calcium level of 10 mg/dL, and reports a headache should be assessed, but the calcium level and headache are less urgent compared to immediate treatment needs for hypoglycemia.

D. A client who was administered acyclovir for cellulitis reports pain in the affected leg may require assessment for infection or medication side effects, but this is less critical than addressing hypoglycemia.

Rationale:

A. Agency policies for the LPN are important but secondary to ensuring the tasks fall within the scope of practice.

B. The documented experience level of the LPN is relevant but should be considered in conjunction with the scope of practice.

C. The documented skill level of the LPN is important for assigning tasks but must align with legal scope of practice.

D. State Nurse Practice Act for the LPN is the priority criterion as it defines the legal scope of practice and ensures that tasks delegated to the LPN are within their legal and professional boundaries.

Rationale:

A. A client who is alert and oriented makes an informed decision to leave the hospital against medical advice. The nurse applies restraints to the client to prevent him from leaving constitutes a violation of patient autonomy and could be considered false imprisonment rather than negligence.

B. A nurse identifies the absence of peripheral pulsation in a casted extremity in the early morning and reports it to the provider in the early afternoon might be considered a delay in care but does not necessarily meet the criteria for negligence unless it leads to harm.

C. A client who is competent refuses an antidepressant medication. The nurse dissolves the medication in food and administers it to her without her knowledge is an example of negligence as it violates the client’s autonomy and informed consent.

D. A nurse finds a client who is on a low-sodium diet eating salted potato chips. The nurse tells the client that she will apply wrist restraints if he does not stop eating the potato chips is inappropriate but does not specifically represent negligence; it’s more about improper behavior or coercion.

Rationale:

A. Blood for PaCO2 is a specialized specimen that requires venipuncture and specific handling to ensure accuracy, which should be performed by a licensed nurse or phlebotomist.

B. Random stool specimen collection is a routine task that can be delegated to the AP. It requires minimal specialized skill and is within the AP's scope of practice.

C. Wound drainage for culture requires sterile technique and proper handling to avoid contamination, which is beyond the AP's responsibilities.

D. Urine from an indwelling catheter requires specialized techniques and knowledge to ensure proper collection, and should be performed by a nurse.

Rationale:

A. Blood for PaCO2 is a specialized specimen that requires venipuncture and specific handling to ensure accuracy, which should be performed by a licensed nurse or phlebotomist.

B. Random stool specimen collection is a routine task that can be delegated to the AP. It requires minimal specialized skill and is within the AP's scope of practice.

C. Wound drainage for culture requires sterile technique and proper handling to avoid contamination, which is beyond the AP's responsibilities.

D. Urine from an indwelling catheter requires specialized techniques and knowledge to ensure proper collection, and should be performed by a nurse.

Rationale:

A. "There are no provider's prescriptions available." is related to background information but does not describe the current situation of the client.

B. "The client was found unconscious on the floor in her home." provides information about the situation but not the current clinical background.

C. "The client should be seen by a neurologist." is a recommendation for further action and should be included in the "Recommendation" section of SBAR, not "Background."

D. "The client is disoriented. Pupils are slow to respond to light." provides relevant background information about the client's current condition, which is necessary for the SBAR "Background" step.

Rationale:

A. A client who is 3 days postoperative following a craniotomy requires careful monitoring due to potential complications from brain surgery, so vital signs should be taken by a nurse.

B. A client who is 3 days postoperative following gastric bypass surgery is stable enough for an AP to obtain vital signs, as the risk of immediate postoperative complications is lower compared to more recent surgeries.

C. A client who is 2 hr postoperative following an abdominal hysterectomy requires close monitoring due to the recent surgery, so vital signs should be obtained by a nurse.

D. A client who is 1 hr postoperative following a thyroidectomy requires vigilant monitoring for potential complications from recent surgery, which should be done by a nurse.

Rationale:

A. An infant who has pertussis and is receiving oxygen via nasal cannula requires immediate assessment to ensure that the oxygen therapy is adequate and to monitor for any signs of respiratory distress or worsening condition.

B. An adolescent who was admitted to the unit in sickle cell crisis and is ready for discharge instructions does not require immediate assessment as the client is stable enough for discharge planning.

C. A school-age child who has diabetes mellitus and requires blood glucose monitoring should be assessed, but it is less urgent compared to a client with a respiratory condition.

D. A toddler who has both arms in casts and needs to be fed his breakfast needs attention, but this is less critical compared to monitoring a client with a respiratory condition.

Rationale:

A. Palpate for possible bladder distention is a task that requires nursing assessment skills and should be done by the nurse.

B. Observe the incision site is a nursing task that involves assessing for signs of complications.

C. Change the abdominal dressing requires sterile technique and should be done by a nurse to prevent infection and ensure proper care.

D. Obtain vital signs is within the AP’s scope of practice and is a task that can be delegated. It is important for monitoring the client’s status and identifying potential issues.

Rationale:

A. Check to see if the elbow restraint is in place for an infant who is postoperative from a surgical correction of a cleft palate is a priority to ensure the safety and proper positioning of a vulnerable postoperative patient.

B. Wash the hair of an adolescent who reports extreme fatigue and is scheduled for radiation therapy for the treatment of Hodgkin lymphoma can be done later, as it is not as critical as ensuring the safety of a postoperative infant.

C. Collect a stool sample for ova and parasites from a school-age child is important but not as urgent as checking restraints for a postoperative infant.

D. Engage a toddler in play is important for developmental support but is not as urgent as tasks directly related to patient safety and postoperative care.

Rationale:

A. A client who reports pain as 4 on a scale of 1 to 10 at 0800 now reports pain as 6 needs pain management, but this is less urgent compared to potential signs of hypotension.

B. A client whose wound drainage at 0800 was sanguineous and now it is serosanguineous indicates normal progression of wound healing; thus, it is less critical.

C. A client who has a prescription for insulin and his premeal capillary blood glucose was 110 mg/dL and his post-meal capillary blood glucose is now 160 mg/dL needs blood glucose management, but this is less urgent than assessing for potential hypovolemia or shock.

D. A client whose blood pressure at 0800 was 138/86 mm Hg and at 1200 is 106/60 mm Hg is experiencing a significant drop in blood pressure, which could indicate hypovolemia or shock. This requires immediate assessment and intervention to prevent complications.

Rationale:

A. A child who is experiencing sickle cell crisis may require isolation to prevent infection and avoid complications related to sickle cell disease.

B. A child who has a head injury may require specific monitoring and precautions that are not suitable for a postoperative appendectomy patient.

C. A child who has a new diagnosis of type 1 diabetes mellitus generally has a stable condition that can be managed with routine care and would be an appropriate roommate for a postoperative appendectomy patient.

D. A child who has streptococcal pharyngitis could pose an infection risk to the postoperative appendectomy patient and is better kept separate to prevent the spread of infection.

Rationale:

A. Set a target date is crucial during the moving stage to create a timeline for implementation and facilitate progress towards the change.

B. Use tactics to alert staff nurses that a change is needed is part of the earlier stage of planning and communicating the need for change, not specifically the moving stage.

C. Evaluate the effectiveness of the change occurs after the change has been implemented, not during the moving stage.

D. Assess the problem is part of the initial stage of change, not the moving stage.

Rationale:

A. A client who has a small circular partial-thickness burn of the left calf requires care, but this is less urgent compared to severe airway or respiratory issues.

B. A client who has a massive head injury and is experiencing seizures is critical but still less urgent compared to immediate life-threatening airway issues.

C. A client who has a splinted open fracture of left medial malleolus requires care but is not as immediately life-threatening as respiratory issues.

D. A client who has severe respiratory stridor and a deviated trachea has a life-threatening airway obstruction that needs immediate intervention to ensure adequate breathing and oxygenation.

Rationale:

A. "If you let us know ahead of time that you plan to perform a procedure, we could do better job of having the supplies available." may be perceived as placing blame and does not address the immediate concern of the provider's anger.

B. "It must be very frustrating when you don't have what you need to perform the procedure." acknowledges the provider's frustration and validates their feelings, which can help de-escalate the situation and improve communication.

C. "I will help you with this procedure instead of the staff nurse." does not address the underlying issue and might not resolve the conflict or improve the situation.

D. "You should think about how you make others feel when you lose your temper." is confrontational and may escalate the situation further rather than resolving it.