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 {"xRanges":[141.765625,171.765625],"yRanges":[127.609375,157.609375]}

Explanation

A. To best hear the closing of the aortic heart valve, the nurse should place the diaphragm of the stethoscope at the second intercostal space, right sternal border. This is also known as the aortic area.
B. This is the tricuspid region, and defects with the tricuspid valve will be best heard in this area.
C. This is the mitral region and murmurs due to defects in the mitral valve will be appreciated here

A. A client who has a history of MRSA will need antibiotics. B. A client who has a history of MRSA can develop immunity to the infection. C. A client who has a history of MRSA requires a protective environment. D. A client who has a history of MRSA can still transmit the infection.

Correct Answer is D

Explanation

A. Not all clients with a history of MRSA will require antibiotics. Treatment depends on the presence of active infection, colonization, and other clinical factors.
B. There is no evidence to suggest that individuals can develop immunity to MRSA. MRSA remains a significant pathogen, and individuals with a history of MRSA remain susceptible to reinfection or colonization.
C. A protective environment is not typically required for clients with a history of MRSA. Standard precautions, including hand hygiene and appropriate use of personal protective equipment, are sufficient to prevent transmission.

D. Clients with a history of MRSA can still carry the bacteria on their skin or in their nasal passages and may transmit the infection to others, especially in healthcare settings. Therefore, it is important to adhere to infection control practices to prevent transmission.

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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

A nurse is assessing a client's cardiovascular system. Identify where the nurse should place the diaphragm of the stethoscope to best hear the closing of the aortic heart valve. (You will find "Hot Spots" to select in the artwork below. Select only the hotspot that corresponds to your answer.)

Correct Answer is {"xRanges":[141.765625,171.765625],"yRanges":[127.609375,157.609375]}

Explanation

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Correct Answer is D

Explanation

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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?