Practice Quiz

NCLEX-RN

Category - Care Management

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The licensed practical nurse (LPN) on the nursing team has notified Nina the New Nurse that a client with cardiomyopathy is complaining of feeling a period of dizziness while ambulating to the bathroom this morning. After assessing the client, Nina the New Nurse compares the blood pressure and heart rate to the vitals taken four hours earlier and determines a decrease in systolic blood pressure (from 150 to 115 mmHG) and increased heart rate (from 78 to 98). Based on her findings, what should Nina the New Nurse instruct the LPN to do?
  1. After the client sits upright for a few minutes before standing, check orthostatic blood pressures (laying, sitting and standing) before rising from bed and in two hours notify the registered nurse (RN) of results
  2. Use her own judgment to decide what should be done
  3. Increase the client’s fluid intake
  4. Place the client in Trendelenburg and recheck blood pressure every 15min. for one hour, then evaluate treatment plan based on results
Explanation
Answer: A and D - As the team leader, it is Nina the New Nurse’s responsibility to oversee the care delivered by the LPN. It is not within the scope of practice of an LPN to assess, implement, or evaluate nursing interventions. The assessment findings indicate postural hypotension related to the client’s condition (cardiomyopathy).
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