Client diagnosed with toxic shock syndrome (TSS). (Correct Answer)
TSS is caused by a Staphylococcus infection that causes vomiting, diarrhea, and shock. Early diagnosis and treatment are critical to avoid involvement with other organ systems. This client should be assigned to the nurse.
Client recovering from an ectopic pregnancy.
The client recovering from an ectopic pregnancy is considered stable and will have an expected outcome. The LPN/LVN can be safely assigned to this client. The UAP can do standard, unchanging procedures.
Client recovering from the removal of a hydatidiform mole.
A hydatidiform mole is a degenerative anomaly of the chorionic villi. Curettage is done to completely remove all molar tissue. The LPN/LVN can be safely assigned to this client. The UAP can do standard, unchanging procedures
Client recovering from a vaginal hysterectomy.
The client recovering from a vaginal hysterectomy needs to be monitored for pain, hemorrhage, and the ability to void. The LPN/LVN can be safely assigned to this client. The UAP can do standard, unchanging procedures.
Decision Tree:
This walk-through provides test-taking strategies to determine the correct answer for the different types of questions you will encounter on the NCLEX-RN exam. These strategies are based on the Kaplan Decision Tree (DT) algorithm, a technique that provides a process to determine the correct answer for NCLEX-style questions.
This is a Delegation Question.
Delegation questions use phrases such as, "Which action is appropriate to delegate to the LPN/LVN, the unlicensed assistive personnel (UAP), etc." Use these steps, based on the DT, to determine the correct answer.
STEP 1: Can you identify the topic of the question?
- Which client is most unstable?
STEPS 2?4: These steps are not relevant to this type of question because you do not need to use the rules for Delegation questions. Move to Step 5.
STEP 5: Apply the rules of delegation to each answer choice
Rules of Delegation:
- RNs cannot delegate assessment, evaluation, nursing judgment, or teaching.
- LPN/LVNs are assigned stable clients with expected outcomes.
- UAPs perform standard, unchanging procedures
Apply the rules:
1. Client diagnosed with TSS. This unstable client is experiencing an acute infection that could progress quickly and develop into shock. Expert nursing assessment and interventions are needed for this changing situation. This client should be assigned to a nurse.
2. Client recovering from an ectopic pregnancy. This client is stable, although ongoing monitoring is needed. Eliminate.
3. Client recovering from an hydatidiform mole.This client is stable, although ongoing monitoring is needed. Eliminate.
4. Client recovering from a vaginal hysterectomy. This client is stable, although ongoing monitoring is needed. Eliminate.
Select the best answer choice:
Is #1 the correct answer? Yes, this client is unstable, which requires the nurse to provide expert assessment, decision-making, and intervention.
Does #1 make sense? Yes, assigning this client to the nurse will provide the most expert nursing care in an unstable and changing situation.
