A nurse is completing a physical assessment of a client who has early osteoarthritis. Which of the following manifestations should the nurse expect?

Choice A reason:

Saying “Maybe next time you can have a vaginal delivery” is not supportive and may minimize the client’s current feelings of disappointment. It is important to acknowledge and validate the client’s emotions rather than focusing on future possibilities.

Choice B reason:

This response, “It sounds like you are feeling sad that things didn’t go as planned,” is empathetic and validates the client’s feelings. It shows that the nurse is listening and understands the client’s disappointment, which is crucial for emotional support.

Choice C reason:

While it is true that having a healthy baby is important, saying “At least you know you have a healthy baby” can come across as dismissive of the client’s feelings. It is essential to address the client’s emotions directly rather than shifting the focus.

Choice D reason:

Telling the client “You can resume sensations sooner than if you had delivered vaginally” is not relevant to the client’s expressed feelings of disappointment about not having a natural childbirth. This response does not address the emotional aspect of the client’s experience.

Choice A reason: Plan a plan of care for a client when postoperative from an appendectomy

Planning a plan of care for a client, especially postoperatively, is a complex task that requires comprehensive assessment and critical thinking skills. This responsibility typically falls within the scope of practice of a registered nurse (RN) rather than an LPN. The RN is trained to develop individualized care plans based on a thorough assessment of the client’s condition, medical history, and specific needs. This ensures that the care plan is holistic and addresses all aspects of the client’s recovery.

Choice B reason: Provide discharge instructions to a confused client’s spouse

Providing discharge instructions, particularly to a confused client’s spouse, involves detailed communication and education. This task is generally performed by an RN, who has the expertise to ensure that the instructions are clear, comprehensive, and tailored to the client’s specific needs. The RN can also assess the spouse’s understanding and provide additional clarification as needed. This ensures that the client receives appropriate care at home and reduces the risk of complications.

Choice C reason: Administer a tap-water enema to a client who is preoperative

Administering a tap-water enema is a task that can be safely delegated to an LPN. LPNs are trained to perform routine procedures such as enemas, which do not require the advanced assessment skills of an RN. This task involves following established protocols and ensuring the client’s comfort and safety during the procedure. By delegating this task to an LPN, the RN can focus on more complex aspects of client care.

Choice D reason: Clean vital signs from a client who is 6 hours postoperative

Obtaining and recording vital signs is a fundamental skill within the LPN’s scope of practice, as it involves routine data collection without interpretation or care‑planning decisions.

Choice E reason: Catheterize a client who has not voided in 8 hours

Catheterization is a procedure that LPNs are trained to perform. This task involves inserting a catheter to relieve urinary retention, which can be a common issue in postoperative clients. LPNs can perform this procedure safely and effectively, following established protocols to minimize the risk of infection and ensure the client’s comfort. Delegating this task to an LPN allows the RN to focus on other critical aspects of client care.