A nurse delegates tasks to a licensed practical nurse (LPN) and an assistive personnel (AP). When admitting a client who is experiencing acute liver failure and who has ascites and an NG tube, which of the following tasks is most appropriate for the nurse to delegate to the LPN?

insert an indwelling catheter if the client has not voided in 3hr

Obtain the abdominal girth now and every 4 hr.

Assess and document the level of consciousness every hour.

Measure the amount of gastric drainage every 2 hrs

Answer and Explanation

The Correct Answer is D

A. Insert an indwelling catheter if the client has not voided in 3 hr: Inserting an indwelling catheter involves an invasive procedure and requires clinical judgment and assessment for contraindications such as coagulopathy, which is common in acute liver failure. This task should remain with the registered nurse (RN) rather than being delegated to an LPN.

B. Obtain the abdominal girth now and every 4 hr: Measuring abdominal girth is a repetitive, non-invasive monitoring task that is within the scope of practice of assistive personnel. The RN should delegate this task to the AP, allowing the LPN to perform tasks requiring slightly higher clinical skills.

C. Assess and document the level of consciousness every hour: Assessing neurological status requires ongoing clinical judgment and the ability to detect subtle changes in mental status, which is critical in clients with hepatic encephalopathy. This responsibility cannot be delegated and must be performed by the RN.

D. Measure the amount of gastric drainage every 2 hrs: Monitoring and documenting the amount of NG tube drainage is within the scope of practice for an LPN. It requires basic assessment skills, accurate measurement, and reporting changes to the RN, making it appropriate to delegate to the LPN.

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Correct Answer is C

Explanation

A. Assist the client to a supine position: There is no requirement to maintain a supine position for bacterial meningitis. Clients are often more comfortable with the head of the bed elevated to reduce intracranial pressure and promote comfort. Supine positioning alone does not prevent disease transmission or improve outcomes.

B. Recommend prophylactic acyclovir for the client's family: Acyclovir is an antiviral medication and is not effective against bacterial infections. Family members may require prophylactic antibiotics if exposed, but antiviral therapy is inappropriate for bacterial meningitis.

C. Initiate droplet precautions for the client: Bacterial meningitis, particularly Neisseria meningitidis, can be transmitted via respiratory droplets. Implementing droplet precautions, including the use of masks and limiting close contact, protects healthcare staff and other clients from infection. This is a standard and critical infection control measure.

D. Perform a Glasgow Coma Scale every 24 hr: Clients with bacterial meningitis are at risk for rapid neurological changes. Performing a Glasgow Coma Scale only once every 24 hours is insufficient. Neurological status should be monitored more frequently to promptly identify deterioration.

A. 3 months B. 6 months C. 9 months D. 12 months

Correct Answer is B

Explanation

A. 3 months: At 3 months, infants typically have a smaller head circumference, weigh less (around 12–13 lb), have fewer teeth, and have not yet demonstrated standing or significant weight-bearing when held. The developmental milestones observed in this infant exceed those expected at 3 months.

B. 6 months: The infant’s weight (14.5 lb), height (24 inches), presence of two lower central incisors, ability to bear weight when held in a standing position, hold a bottle, and exhibit a social smile align with typical developmental milestones for a 6-month-old. Neurologic reflexes such as Moro and tonic neck reflexes usually disappear by this age.

C. 9 months: By 9 months, infants are usually able to sit without support, may begin crawling, and have more teeth. The inability to sit unsupported indicates the infant is younger than 9 months.

D. 12 months: At 12 months, infants generally are able to stand independently, may begin walking, and have more advanced fine motor skills and additional teeth. The developmental abilities and physical measurements of this infant suggest she is younger than 12 months.

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A nurse delegates tasks to a licensed practical nurse (LPN) and an assistive personnel (AP). When admitting a client who is experiencing acute liver failure and who has ascites and an NG tube, which of the following tasks is most appropriate for the nurse to delegate to the LPN?

Nursing Test Bank

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Correct Answer is C

Explanation

Correct Answer is B

Explanation

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