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

Answer and Explanation

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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Correct Answer is A

Explanation

A. Discarding opened cans of formula after 24 hours helps prevent bacterial contamination and growth, which can contribute to diarrhea in clients receiving enteral feedings.

B. Extension tubing should be replaced according to institutional policy and manufacturer recommendations, typically every 24 to 48 hours, but it is not directly related to diarrhea management.

C. Irrigating the tubing with warm water is not a standard practice for managing diarrhea in clients receiving enteral feedings and may disrupt the client's fluid and electrolyte balance.

D. Increasing the infusion rate of enteral feedings is not indicated for managing diarrhea and may exacerbate the problem by overwhelming the client's gastrointestinal tract. The rate of enteral feeding should be adjusted based on the client's nutritional needs and tolerance, as determined by the healthcare provider.

A. Repeats the words of others when speaking B. Speaks in word salad C. Expresses interest in ADLs (Activities of Daily Living) D. Has a blunt affect E. Experiences delusions

Correct Answer is ["A","B","D","E"]

Explanation

A. Echolalia, or repeating the words of others, can be a manifestation of schizophrenia.

B. Word salad, or a jumble of incoherent words and phrases, can occur in schizophrenia.

C. Expressing interest in ADLs is not typically associated with schizophrenia and may indicate a different mental health state.

D. A blunt affect, or reduced emotional expression, is a common symptom of schizophrenia.

E. Delusions, or fixed false beliefs, are a hallmark symptom of schizophrenia.

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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?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is ["A","B","D","E"]

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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?