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 3 hr.
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 hr.
None
None
The Correct Answer is D
A. Inserting an indwelling catheter involves an invasive procedure and assessment of urinary output and client status, which falls within the RN’s scope of practice in a high-risk client such as one with acute liver failure.
B. Obtaining abdominal girth requires assessment skills and interpretation for changes in ascites, which is more appropriate for the RN to ensure accurate monitoring.
C. Assessing and documenting level of consciousness is a critical assessment, especially in liver failure where hepatic encephalopathy is a risk. This is within the RN’s responsibility because changes can be subtle and require immediate intervention.
D. Measuring the amount of gastric drainage every 2 hours is a stable, routine task that follows established parameters and does not require advanced assessment skills. It is within the LPN’s scope and can be safely delegated, with the RN overseeing interpretation of any abnormal findings.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Allergies to eggs are not typically a contraindication for a thyroid scan.
B. Latex allergies are not typically a contraindication for a thyroid scan unless latex-containing materials are involved in the procedure, such as gloves or adhesive bandages.
C. Allergies to peanuts are not typically a contraindication for a thyroid scan.
D. Iodine is the main component of the radioactive tracer used in a thyroid scan. If the client has a known allergy to iodine, it would be unsafe for them to undergo the scan.
Correct Answer is A
Explanation
A. A flat anterior fontanel can indicate dehydration in infants, so this finding does not indicate effective treatment.
B. Oliguria, or decreased urine output, is a sign of dehydration and would not indicate effective treatment.
C. Oral intake of 4 oz every 3 hours indicates that the infant is able to drink fluids and is likely rehydrated, indicating effective treatment.
D. A capillary refill of 4 seconds is prolonged and can indicate poor perfusion, which is not indicative of effective treatment for dehydration.
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