A nurse in a long-term care facility is planning care for several clients. Which of the following activities should the nurse delegate to the licensed practical nurse (LPN)?

Choice A rationale:

Offering a glass of water to the patient is not a priority action when dealing with a surgical incision that eviscerates. This situation requires immediate intervention to prevent complications related to the evisceration.

Choice B rationale:

Monitoring the patient for signs and symptoms of shock is crucial in this scenario. Evisceration, the protrusion of organs from a surgical incision, can lead to significant blood loss, which may result in shock. Signs of shock include hypotension, tachycardia, pallor, diaphoresis, and altered mental status.

Choice C rationale:

Placing moist sterile gauze over the site is appropriate to prevent the exposed organs from drying out and becoming further damaged. It also helps to reduce the risk of infection. Moist sterile gauze helps maintain a sterile environment and prevents the organs from being exposed to contaminants.

Choice D rationale:

Gently placing the organs back into the abdominal cavity is not within the nurse's scope of practice. This action requires surgical intervention by a healthcare provider. The nurse's role is to provide immediate first aid and notify the surgeon.

Choice E rationale:

Contacting the patient's surgeon is essential. Evisceration is a surgical emergency, and the surgeon needs to be informed promptly to make decisions regarding further interventions. The patient may require emergency surgery to address the evisceration and prevent complications.

Choice A rationale:

Encouraging the client to ambulate frequently is important for preventing complications associated with immobility, such as deep vein thrombosis and muscle atrophy. However, it is not a direct intervention for promoting the thinning of respiratory secretions.

Choice B rationale:

Encouraging the client to increase fluid intake is a valuable intervention to help thin respiratory secretions. However, the most effective method mentioned here is the use of the incentive spirometer, which directly assists the client in taking deep breaths and enhancing lung function.

Choice C rationale:

Encouraging regular use of the incentive spirometer is a crucial intervention for promoting the thinning of respiratory secretions. Incentive spirometry helps prevent atelectasis (collapse of lung tissue) and promotes deep breathing, which aids in clearing secretions and maintaining lung health.

Choice D rationale:

Encouraging coughing and deep breathing is generally important for maintaining lung health and preventing complications like pneumonia. However, the specific action of using the incentive spirometer is more targeted and effective for promoting respiratory secretion clearance in clients with pneumonia.