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.
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Related Questions
Correct Answer is D
Explanation
A. Portable suction may be needed for some infants but is not specifically indicated for tetralogy of Fallot.
B. A cervical collar is used for neck support in patients with suspected cervical spine injuries and is not indicated for tetralogy of Fallot.
C. A hemodialyzer is used for renal replacement therapy and is not indicated for tetralogy of Fallot.
D. A pulse oximeter is essential for monitoring oxygen saturation levels in infants with tetralogy of Fallot, as they may experience cyanosis and hypoxemia. Monitoring oxygen saturation helps guide interventions and management.
Correct Answer is A
Explanation
A.
A. Early decelerations are typically benign and occur in response to head compression during contractions. They mirror the uterine contractions and are not associated with fetal distress.
B. Fetal hypoxia is associated with variable or late decelerations, not early decelerations.
C. Abruptio placentae is a medical emergency characterized by premature separation of the placenta from the uterine wall, which can lead to late decelerations due to fetal hypoxia.
D. Postmaturity is a term used to describe a pregnancy that extends beyond 42 weeks gestation and is not directly related to fetal heart rate patterns during labor.
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