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 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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Related Questions
Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"A"}
Explanation
The nurse should first administer the client's cefazolinto the client's IV access
Rationale:
Cefazolin is an antibiotic prescribed to treat the client's suspected infection indicated by the fever and hip surgical wound inflammation. Administering the antibiotic promptly is essential to initiate treatment and address the underlying cause of the fever. The prescription specifies administering cefazolin intravenously, so the nurse should prioritize administering it through the client's IV access. Administering acetaminophen or alprazolam may be appropriate based on the client's symptoms and vital signs, but addressing the infection with antibiotics takes precedence.
Correct Answer is B
Explanation
A. Cannabis withdrawal typically presents with symptoms such as irritability, anxiety, insomnia, decreased appetite, and physical discomfort, but not constricted pupils, delayed reflexes, and decreased blood pressure.
B. Opioid intoxication can cause constricted pupils (miosis), delayed reflexes, and decreased blood pressure, among other symptoms such as respiratory depression, drowsiness, and altered mental status.
C. Amphetamine intoxication typically presents with symptoms such as dilated pupils, increased blood pressure, tachycardia, agitation, and hallucinations, but not constricted pupils, delayed reflexes, and decreased blood pressure.
D. Alcohol withdrawal typically presents with symptoms such as tremors, anxiety, agitation, hallucinations, increased heart rate and blood pressure, but not constricted pupils, delayed reflexes, and decreased blood pressure.
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