A nurse and an experienced licensed practical nurse (LPN) are caring for a group of clients. Which of the following tasks should the nurse delegate to the LPN? (Select all that apply)

Plan a plan of care for a client when postoperative from an appendectomy

Provide discharge instructions to a confused client’s spouse

Administer a tap-water enema to a client who is preoperative

Clean vital signs from a client who is 6 hours postoperative

Catheterize a client who has not voided in 8 hours

Answer and Explanation

Correct Answer : C,D,E

Choice A reason: Plan a plan of care for a client when postoperative from an appendectomy

Planning a plan of care for a client, especially postoperatively, is a complex task that requires comprehensive assessment and critical thinking skills. This responsibility typically falls within the scope of practice of a registered nurse (RN) rather than an LPN. The RN is trained to develop individualized care plans based on a thorough assessment of the client’s condition, medical history, and specific needs. This ensures that the care plan is holistic and addresses all aspects of the client’s recovery.

Choice B reason: Provide discharge instructions to a confused client’s spouse

Providing discharge instructions, particularly to a confused client’s spouse, involves detailed communication and education. This task is generally performed by an RN, who has the expertise to ensure that the instructions are clear, comprehensive, and tailored to the client’s specific needs. The RN can also assess the spouse’s understanding and provide additional clarification as needed. This ensures that the client receives appropriate care at home and reduces the risk of complications.

Choice C reason: Administer a tap-water enema to a client who is preoperative

Administering a tap-water enema is a task that can be safely delegated to an LPN. LPNs are trained to perform routine procedures such as enemas, which do not require the advanced assessment skills of an RN. This task involves following established protocols and ensuring the client’s comfort and safety during the procedure. By delegating this task to an LPN, the RN can focus on more complex aspects of client care.

Choice D reason: Clean vital signs from a client who is 6 hours postoperative

Obtaining and recording vital signs is a fundamental skill within the LPN’s scope of practice, as it involves routine data collection without interpretation or care‑planning decisions.

Choice E reason: Catheterize a client who has not voided in 8 hours

Catheterization is a procedure that LPNs are trained to perform. This task involves inserting a catheter to relieve urinary retention, which can be a common issue in postoperative clients. LPNs can perform this procedure safely and effectively, following established protocols to minimize the risk of infection and ensure the client’s comfort. Delegating this task to an LPN allows the RN to focus on other critical aspects of client care.

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Correct Answer is B

Explanation

Choice A reason:

Saying “Maybe next time you can have a vaginal delivery” is not supportive and may minimize the client’s current feelings of disappointment. It is important to acknowledge and validate the client’s emotions rather than focusing on future possibilities.

Choice B reason:

This response, “It sounds like you are feeling sad that things didn’t go as planned,” is empathetic and validates the client’s feelings. It shows that the nurse is listening and understands the client’s disappointment, which is crucial for emotional support.

Choice C reason:

While it is true that having a healthy baby is important, saying “At least you know you have a healthy baby” can come across as dismissive of the client’s feelings. It is essential to address the client’s emotions directly rather than shifting the focus.

Choice D reason:

Telling the client “You can resume sensations sooner than if you had delivered vaginally” is not relevant to the client’s expressed feelings of disappointment about not having a natural childbirth. This response does not address the emotional aspect of the client’s experience.

A. Obtain a 12-lead ECG. B. Suggest that the client use a salt substitute. C. Advise the client to add citrus juices and bananas to her diet. D. Obtain a blood sample for a serum sodium level.

Correct Answer is A

Explanation

Choice A reason: Obtain a 12-lead ECG

Obtaining a 12-lead ECG is a critical action when a client has a potassium level of 6.8 mEq/L, which indicates hyperkalemia. Hyperkalemia can cause serious cardiac dysrhythmias, including life-threatening arrhythmias such as ventricular fibrillation or asystole. An ECG can help detect these abnormalities early, allowing for prompt intervention to prevent cardiac complications. The ECG may show characteristic changes such as peaked T waves, widened QRS complexes, and prolonged PR intervals, which are indicative of hyperkalemia.

Choice B reason: Suggest that the client use a salt substitute

Suggesting that the client use a salt substitute is not appropriate in this situation. Many salt substitutes contain potassium chloride, which can further increase the potassium level in the blood. For a client with hyperkalemia, it is crucial to avoid additional sources of potassium to prevent exacerbating the condition. Therefore, recommending a salt substitute could be harmful.

Choice C reason: Advise the client to add citrus juices and bananas to her diet

Advising the client to add citrus juices and bananas to her diet is also inappropriate. Both citrus juices and bananas are high in potassium and can contribute to an increase in serum potassium levels. For a client with hyperkalemia, it is essential to limit dietary potassium intake to help lower the potassium levels in the blood. Encouraging the consumption of high-potassium foods would be counterproductive and potentially dangerous.

Choice D reason: Obtain a blood sample for a serum sodium level

While obtaining a blood sample for a serum sodium level can be part of a comprehensive assessment, it is not the immediate priority in managing hyperkalemia. The primary concern with a potassium level of 6.8 mEq/L is the risk of cardiac dysrhythmias. Therefore, obtaining an ECG to monitor the heart’s electrical activity is the most urgent and appropriate action. Once the immediate risk is addressed, further laboratory tests, including serum sodium levels, can be conducted as part of the overall assessment and management plan.

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A nurse and an experienced licensed practical nurse (LPN) are caring for a group of clients. Which of the following tasks should the nurse delegate to the LPN? (Select all that apply)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is A

Explanation

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