A nurse and an experienced licensed practical nurse (LPN) are caring for a group of clients. Which of the following tasks should the nurse delegate to the LPN? (Select all that apply)

Plan a plan of care for a client when postoperative from an appendectomy

Provide discharge instructions to a confused client’s spouse

Administer a tap-water enema to a client who is preoperative

Clean vital signs from a client who is 6 hours postoperative

Catheterize a client who has not voided in 8 hours

Answer and Explanation

Correct Answer : C,D,E

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.

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Correct Answer is B

Explanation

Choice A reason:

While articulating expectations is important, the nurse’s response is more focused on addressing the client’s feelings and encouraging participation in therapy. Simply stating expectations without addressing the client’s emotions may not be as effective.

Choice B reason:

The nurse’s response demonstrates empathy by acknowledging the client’s feelings and gently guiding them towards participating in group therapy. This approach helps build trust and rapport, which are essential in therapeutic relationships, especially with clients exhibiting delusional behavior.

Choice C reason:

Setting limits on manipulative behavior is important, but in this context, the nurse’s response is more about encouraging participation and showing understanding rather than strictly setting limits.

Choice D reason:

Reflection involves mirroring the client’s feelings or statements to show understanding. While the nurse’s response does show understanding, it is not a direct example of reflection. The primary focus is on empathy and encouragement.

A. Administer the medications 5 minutes apart. B. Hold pressure on the conjunctival sac for 2 minutes following application of drops. C. It is not necessary to remove contact lenses before administering medications. D. Administer the medications by touching the tip of the dropper to the sclera of the eye.

Correct Answer is A

Explanation

Choice A reason: Administer the Medications 5 Minutes Apart

Administering the medications 5 minutes apart is crucial when using multiple eye drops. This practice ensures that each medication has enough time to be absorbed without being washed out by the subsequent drop. This is particularly important for medications like timolol and pilocarpine, which are used to manage intraocular pressure in glaucoma.

Choice B reason: Hold Pressure on the Conjunctival Sac for 2 Minutes Following Application of Drops

Holding pressure on the conjunctival sac (punctal occlusion) for 2 minutes after applying eye drops can help reduce systemic absorption and increase the local effect of the medication. However, this instruction is not as critical as the timing between administering different eye drops.

Choice C reason: It Is Not Necessary to Remove Contact Lenses Before Administering Medications

This statement is incorrect. Contact lenses should be removed before administering eye drops to prevent contamination and ensure proper absorption of the medication. The lenses can be reinserted after a sufficient amount of time has passed, usually around 15 minutes.

Choice D reason: Administer the Medications by Touching the Tip of the Dropper to the Sclera of the Eye

This statement is incorrect. The tip of the dropper should never touch the eye or any other surface to avoid contamination. The correct method is to hold the dropper above the eye and squeeze out the prescribed number of drops into the conjunctival sac.

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A nurse and an experienced licensed practical nurse (LPN) are caring for a group of clients. Which of the following tasks should the nurse delegate to the LPN? (Select all that apply)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is B

Explanation

A nurse at an ophthalmology clinic is providing teaching to a client who has open-angle glaucoma and a new treatment regimen of timolol and pilocarpine eye drops. Which of the following instructions should the nurse provide?

Correct Answer is A

Explanation

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