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
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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Related Questions
Correct Answer is A
Explanation
Choice A reason: Administer the Medications 5 Minutes Apart
Administering the medications 5 minutes apart is crucial when using multiple eye drops. This practice ensures that each medication has enough time to be absorbed without being washed out by the subsequent drop. This is particularly important for medications like timolol and pilocarpine, which are used to manage intraocular pressure in glaucoma.
Choice B reason: Hold Pressure on the Conjunctival Sac for 2 Minutes Following Application of Drops
Holding pressure on the conjunctival sac (punctal occlusion) for 2 minutes after applying eye drops can help reduce systemic absorption and increase the local effect of the medication. However, this instruction is not as critical as the timing between administering different eye drops.
Choice C reason: It Is Not Necessary to Remove Contact Lenses Before Administering Medications
This statement is incorrect. Contact lenses should be removed before administering eye drops to prevent contamination and ensure proper absorption of the medication. The lenses can be reinserted after a sufficient amount of time has passed, usually around 15 minutes.
Choice D reason: Administer the Medications by Touching the Tip of the Dropper to the Sclera of the Eye
This statement is incorrect. The tip of the dropper should never touch the eye or any other surface to avoid contamination. The correct method is to hold the dropper above the eye and squeeze out the prescribed number of drops into the conjunctival sac.
Correct Answer is B
Explanation
Choice A reason:
Creatinine: Creatinine is a waste product produced by muscles and is filtered out of the blood by the kidneys. Elevated creatinine levels can indicate kidney dysfunction. However, in this scenario, the primary concern is liver damage due to the combination of alcohol and acetaminophen, making AST a more relevant marker.
Choice B reason:
Aspartate aminotransferase (AST): AST is an enzyme found in the liver and heart. Elevated levels of AST can indicate liver damage. Given the client’s high intake of both alcohol and acetaminophen, there is a significant risk of liver damage. Monitoring AST levels can help assess the extent of liver injury.
Choice C reason:
Amylase: Amylase is an enzyme produced by the pancreas and salivary glands that helps in the digestion of carbohydrates. Elevated amylase levels are typically associated with pancreatic disorders, such as pancreatitis. While important, it is not the priority in this case where liver damage is the main concern.
Choice D reason:
Antidiuretic hormone (ADH): ADH is a hormone that helps regulate water balance in the body by controlling the amount of water reabsorbed by the kidneys. Abnormal levels of ADH can indicate issues with fluid balance, but it is not directly related to liver function or the effects of alcohol and acetaminophen.
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