A nurse is preparing to administer a nasogastric (NG) tube feeding to a school-age child. Which of the following actions should the nurse plan to take?

Rationale:

A. Perform a sterile dressing change for a client who has an abdominal wound: LPNs can perform sterile procedures and wound care on stable clients, making this an appropriate delegated task.

B. Complete the Glasgow Coma Scale for a client who has an evolving stroke: Neurological assessments on unstable or acutely changing clients require RN judgment and should not be delegated to an LPN.

C. Perform an admission assessment for a client who is scheduled for surgery: Admission assessments require comprehensive data collection, interpretation, and nursing judgment, which fall under the RN scope of practice.

D. Complete discharge teaching for a client who has a new diagnosis of diabetes mellitus: Discharge teaching for a new condition involves complex education and evaluation of understanding, which are RN responsibilities.

A. Raise the side rails up when the client is in bed: Full side rails can increase the risk of entrapment and injury for clients with dementia. They are not recommended as a routine safety measure unless individually assessed and ordered.

B. Place the bedside table at the foot of the bed: Placing furniture at the foot of the bed can create obstacles and increase the risk of trips and falls. The environment should be arranged to allow safe, unobstructed mobility.

C. Keep the television on during the night: Continuous noise, such as a TV, can cause agitation or confusion in clients with dementia, increasing the risk of disorientation and injury. Quiet, calming environments are preferred.

D. Assist the client to the toilet frequently: Clients with dementia are at increased risk for falls due to urgency, confusion, or impaired mobility. Frequent toileting assistance reduces the risk of incontinence-related hazards and falls, promoting safety and dignity.