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 A

A. Inserting an indwelling urinary catheter is within the scope of practice of an LPN and is an appropriate task to delegate.
B. Measuring abdominal girth involves assessment of ascites progression, which requires the nurse’s judgment and should not be delegated.
C. Assessing and documenting the client’s level of consciousness requires critical nursing judgment and must be performed by the RN.
D. Measuring gastric drainage every 2 hr is an appropriate task for an AP, not specifically requiring an LPN.

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Correct Answer is C

Explanation

A. Rupturing the amniotic sac in the case of complete placenta previa can lead to significant bleeding and is contraindicated.

B. Pain medication may be administered if needed, but the priority is to address the placenta previa and potential complications.

C. Complete placenta previa at 36 weeks gestation with contractions and bleeding is a clear

indication for an emergency cesarean section to prevent maternal hemorrhage and fetal distress.

D. Performing a vaginal exam can increase the risk of bleeding and should be avoided in cases of placenta previa.

A. Metoprolol B. Clopidogrel C. Metformin D. Digoxin

Correct Answer is C

Explanation

A. Metoprolol is a beta-blocker used to treat hypertension and other cardiovascular conditions.

While it may be important for the provider to be aware of all medications, it is not the priority to report in this scenario.

B. Clopidogrel is an antiplatelet medication used to prevent blood clots in individuals at risk for cardiovascular events. While it may have implications for the procedure, it is not the priority to report in this scenario.

C. Metformin is an oral antidiabetic medication commonly used to treat type 2 diabetes. It is

important to report because there may be specific considerations regarding its use in the context of a colonoscopy, such as the risk of lactic acidosis.

D. Digoxin is a medication used to treat heart failure and certain arrhythmias. While it may have implications for the procedure, it is not the priority to report in this scenario.

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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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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?