A nurse is caring for a group of clients on a hospital unit with the assistance of a licensed practical nurse [LPN]. Which aspect of client care would be the most appropriate for the nurse to delegate to the LPN?

Administering oral antibiotics to a client with UTI.

Teaching a client with a new order for a renal angiogram.

Evaluate the outflow of peritoneal diasylate.

Assess a client with flank pain due to glomerulonephritis.

Answer and Explanation

The Correct Answer is A

A) Administering oral antibiotics to a client with UTI:
Administering oral antibiotics is an appropriate task to delegate to a licensed practical nurse (LPN). LPNs are trained to administer medications, including oral antibiotics, and to monitor for common side effects or adverse reactions. Since the task is routine and does not require advanced clinical judgment, it can be delegated to the LPN under the nurse’s supervision.

B) Teaching a client with a new order for a renal angiogram:
Teaching a client about a new diagnostic procedure, such as a renal angiogram, requires advanced knowledge and clinical judgment to explain the procedure, its risks, and the necessary pre- and post-procedure care. This task is best performed by a registered nurse (RN) because it involves providing detailed patient education and addressing the patient’s concerns.

C) Evaluate the outflow of peritoneal dialysate:
Evaluating the outflow of peritoneal dialysate is a more complex task that involves assessing the effectiveness of the dialysis process and identifying any potential complications (e.g., infection, leakage). This task requires clinical expertise in dialysis and the ability to interpret changes in the output. Although LPNs may assist in monitoring the process, it is ultimately the RN’s responsibility to evaluate the outcome, interpret any changes, and intervene if necessary.

D) Assess a client with flank pain due to glomerulonephritis:
Assessment of a client with flank pain related to glomerulonephritis requires a thorough evaluation of the client's condition, including understanding the potential causes of pain and monitoring for complications such as renal failure or infection. This type of assessment requires critical thinking and clinical judgment, making it the responsibility of the RN.

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Correct Answer is A

Explanation

A. Prepare for defibrillation: Defibrillation is the priority intervention for ventricular fibrillation, as it is the most effective treatment to terminate this life-threatening arrhythmia. Rapid defibrillation can restore a perfusing rhythm, which is critical for survival in a client who is unresponsive, pulseless, and apneic.

B. Atropine administration: Atropine is used to treat bradycardia or asystole but is not effective for ventricular fibrillation. In this scenario, defibrillation takes precedence over medication administration to restore a normal heart rhythm.

C. Prepare for synchronized cardioversion: Synchronized cardioversion is used for certain tachyarrhythmias when the client has a pulse. Ventricular fibrillation requires immediate unsynchronized defibrillation because the client is pulseless and unresponsive.

D. Amiodarone administration: Amiodarone is an antiarrhythmic drug that can be used after defibrillation and chest compressions to stabilize the heart rhythm. However, it is not the initial action in this emergency; defibrillation must occur first to terminate the arrhythmia and restore circulation.

A. Normal saline 1 liter to client who is dehydrated B. Morphine sulfate 4mg intravenously (IV) now for the client experiencing incisional pain C. Nitroglycerin (Nitrostat) 0.4 mg sublingually (SL) stat for the client experiencing crushing chest pain D. Lorazepam 2 mg IV now for the client who is anxious and restless

Correct Answer is C

Explanation

A) Normal saline 1 liter to client who is dehydrated:
Administering normal saline to a dehydrated client is an important task, as it helps to restore fluid balance and improve circulatory volume. However, while rehydration is critical, it is not an immediate, life-threatening priority compared to other interventions. The nurse should begin this infusion after addressing more urgent needs such as severe chest pain, which could indicate a cardiac emergency.

B) Morphine sulfate 4mg intravenously (IV) now for the client experiencing incisional pain:
Morphine is a potent analgesic, and relieving pain for postoperative patients is essential for comfort and recovery. However, incisional pain, although important to address, is not life-threatening in this scenario. The client with chest pain should be prioritized because chest pain could indicate a myocardial infarction (MI) or other serious cardiac event that requires immediate intervention.

C) Nitroglycerin (Nitrostat) 0.4 mg sublingually (SL) stat for the client experiencing crushing chest pain:
Crushing chest pain is a classic symptom of acute myocardial infarction (MI), a life-threatening condition that requires immediate intervention. Nitroglycerin is used to relieve chest pain associated with angina or MI by dilating the coronary arteries and improving blood flow to the heart. In this case, chest pain is the most critical symptom, and immediate treatment is necessary to reduce the risk of further cardiac damage or complications.

D) Lorazepam 2 mg IV now for the client who is anxious and restless:
While lorazepam is an effective medication for anxiety and restlessness, it is not the most urgent medication in this case. The client’s anxiety should be addressed, but it does not pose an immediate threat to life. Anxiety can generally be managed after more acute, life-threatening conditions (such as chest pain) are stabilized.

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A nurse is caring for a group of clients on a hospital unit with the assistance of a licensed practical nurse [LPN]. Which aspect of client care would be the most appropriate for the nurse to delegate to the LPN?

Nursing Test Bank

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Correct Answer is A

Explanation

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Correct Answer is C

Explanation

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