A registered nurse (RN) and an experienced licensed practical nurse (LPN) are caring for a group of clients. Which of the following tasks should the RN delegate to the LPN? SELECT ALL THAT APPLY
Initiate a plan of care for a client who is postoperative from an appendectomy.
Administer a tap-water enema to a client who is preoperative.
Provide discharge instructions to a confused client's spouse.
Catheterize a client who has not voided in 8 hours.
Obtain vital signs from a client who is 6 hours postoperative.
Correct Answer : B,D,E
Choice A reason: Initiating a plan of care for a client who is postoperative from an appendectomy is not a task that the RN should delegate to the LPN, as it requires nursing judgment, critical thinking, and assessment skills that are beyond the scope of practice of the LPN. The RN is responsible for developing, implementing, and evaluating the plan of care for each client based on their individual needs, preferences, and goals. The RN can delegate some aspects of the plan of care to the LPN, such as performing routine tasks or monitoring the client's status, but the RN must supervise and evaluate the LPN's performance.
Choice B reason: Administering a tap-water enema to a client who is preoperative is a task that the RN can delegate to the LPN, as it is a standardized procedure that does not require nursing judgment or assessment. The LPN has the knowledge and skills to perform this task safely and effectively, following the established policies and protocols of the facility. The RN should provide clear instructions and expectations to the LPN, such as the type, amount, and temperature of the solution, the position and comfort of the client, and the signs and symptoms to report. The RN should also verify that the LPN has completed the task and documented the outcome.
Choice C reason: Providing discharge instructions to a confused client's spouse is not a task that the RN should delegate to the LPN, as it involves teaching, counseling, and evaluating the client's and family's understanding and readiness for discharge. These are complex activities that require nursing judgment, communication skills, and evaluation skills that are beyond the scope of practice of the LPN. The RN is responsible for ensuring that the client and family receive adequate information and education about the client's condition, treatment, medications, follow-up care, and community resources. The RN can delegate some aspects of discharge planning to the LPN, such as collecting data or providing reinforcement of teaching, but the RN must supervise and evaluate the LPN's performance.
Choice D reason: Catheterizing a client who has not voided in 8 hours is a task that the RN can delegate to the LPN, as it is a standardized procedure that does not require nursing judgment or assessment. The LPN has the knowledge and skills to perform this task safely and effectively, following the established policies and protocols of the facility. The RN should provide clear instructions and expectations to the LPN, such as the type and size of the catheter, the sterile technique, and the urine output measurement. The RN should also verify that the LPN has completed the task and documented the outcome.
Choice E reason: Obtaining vital signs from a client who is 6 hours postoperative is a task that the RN can delegate to the LPN, as it is a routine task that does not require nursing judgment or assessment. The LPN has the knowledge and skills to perform this task safely and effectively, using appropriate equipment and techniques. The RN should provide clear instructions and expectations to the LPN, such as the frequency and parameters of vital signs monitoring. The RN should also verify that the LPN has completed the task and documented the outcome.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Mitigation is not the correct level of the National Response Framework, as it refers to the actions taken to reduce or eliminate the long-term risk to human life and property from natural or man-made hazards. Mitigation activities include implementing building codes, zoning ordinances, land use planning, and flood insurance programs. Mitigation is a continuous process that occurs before, during, and after a disaster.
Choice B reason: Security is not the correct level of the National Response Framework, as it refers to the actions taken to protect the nation from threats or attacks by terrorists, criminals, or hostile states. Security activities include conducting intelligence operations, screening travelers and cargo, enforcing laws and regulations, and preventing cyberattacks. Security is a shared responsibility among federal, state, local, tribal, territorial, and private sector partners.
Choice C reason: Preparedness is the correct level of the National Response Framework, as it refers to the actions taken to plan, organize, equip, train, and exercise to build and sustain the capabilities necessary to prevent, protect against, mitigate the effects of, respond to, and recover from those threats that pose the greatest risk. Preparedness activities include developing emergency plans, conducting drills and exercises, educating the public, and establishing partnerships and coordination mechanisms. Preparedness is a continuous cycle of improvement that involves assessing needs, setting goals, implementing plans, and evaluating outcomes.
Choice D reason: The response phase is not the correct level of the National Response Framework, as it refers to the actions taken to save lives, protect property and the environment, stabilize the situation, and meet basic human needs in the immediate aftermath of a disaster. Response activities include activating emergency operations centers, deploying resources and personnel, providing mass care and sheltering, restoring critical infrastructure and services, and conducting search and rescue operations. Response is a short-term process that aims to restore normalcy as soon as possible.
Correct Answer is A
Explanation
Choice A reason: Monitoring vital signs and neurological status frequently is a priority intervention for a client who has experienced a hemorrhagic stroke, as it helps to detect any changes in the client's condition and guide appropriate treatment. Hemorrhagic stroke is a medical emergency that occurs when a blood vessel in the brain ruptures and causes bleeding into the brain tissue. This can lead to increased intracranial pressure, cerebral edema, and brain damage. Therefore, the nurse should monitor the client's blood pressure, pulse, respiration, temperature, level of consciousness, pupil reaction, motor function, and sensory function frequently and report any abnormalities to the health care provider.
Choice B reason: Maintaining strict bed rest to minimize cerebral blood flow is not a priority intervention for a client who has experienced a hemorrhagic stroke, as it may not prevent further bleeding or improve the client's outcome. In fact, strict bed rest may increase the risk of complications such as deep vein thrombosis, pulmonary embolism, pneumonia, pressure ulcers, and muscle atrophy. The nurse should follow the health care provider's orders regarding the client's activity level and position. The nurse should also provide adequate hydration, nutrition, skin care, and comfort measures to the client.
Choice C reason: Administering anticoagulant medications as prescribed is not a priority intervention for a client who has experienced a hemorrhagic stroke, as it may worsen the bleeding and increase the risk of intracranial hemorrhage. Anticoagulant medications are used to prevent or treat ischemic stroke, which is caused by a blood clot that blocks a blood vessel in the brain. However, anticoagulant medications are contraindicated in hemorrhagic stroke, as they interfere with the blood's ability to clot and stop the bleeding. The nurse should avoid giving any medications that may affect coagulation or platelet function to the client unless ordered by the health care provider.
Choice D reason: Assisting the client with active range of motion exercises is not a priority intervention for a client who has experienced a hemorrhagic stroke, as it may not improve the client's neurological function or prevent complications. Active range of motion exercises are performed by the client with or without assistance from the nurse to maintain joint mobility and muscle strength. However, these exercises are not indicated in the acute phase of hemorrhagic stroke, as they may increase intracranial pressure or cause pain or discomfort to the client. The nurse should consult with the physical therapist before initiating any exercise program for the client.
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