A nurse delegates tasks to a licensed practical nurse (LPN) and an assistive personnel (AP). When admitting a client who is experiencing acute liver failure and who has ascites and an NG tube, which of the following tasks is most appropriate for the nurse to delegate to the LPN?

insert an indwelling catheter if the client has not voided in 3hr

Obtain the abdominal girth now and every 4 hr.

Assess and document the level of consciousness every hour.

Measure the amount of gastric drainage every 2 hrs

Answer and Explanation

The Correct Answer is D

A. Insert an indwelling catheter if the client has not voided in 3 hr: Inserting an indwelling catheter involves an invasive procedure and requires clinical judgment and assessment for contraindications such as coagulopathy, which is common in acute liver failure. This task should remain with the registered nurse (RN) rather than being delegated to an LPN.

B. Obtain the abdominal girth now and every 4 hr: Measuring abdominal girth is a repetitive, non-invasive monitoring task that is within the scope of practice of assistive personnel. The RN should delegate this task to the AP, allowing the LPN to perform tasks requiring slightly higher clinical skills.

C. Assess and document the level of consciousness every hour: Assessing neurological status requires ongoing clinical judgment and the ability to detect subtle changes in mental status, which is critical in clients with hepatic encephalopathy. This responsibility cannot be delegated and must be performed by the RN.

D. Measure the amount of gastric drainage every 2 hrs: Monitoring and documenting the amount of NG tube drainage is within the scope of practice for an LPN. It requires basic assessment skills, accurate measurement, and reporting changes to the RN, making it appropriate to delegate to the LPN.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is D

Explanation

A. Inform the client of available community resources: While providing information about resources is important for ongoing support, it is secondary to assessing the client’s current understanding and emotional state regarding their terminal diagnosis.

B. Assist the client in finding child care options: Child care support is a practical need but should be addressed after establishing the client’s comprehension of their condition and immediate priorities for care and planning.

C. Agree upon short-term goals for the client: Goal setting is essential for care planning, but it depends on the client’s understanding of their prognosis and needs. Establishing understanding first ensures that goals are realistic and meaningful.

D. Ask the client about their understanding of the diagnosis: Clarifying the client’s understanding is the priority because it guides all subsequent teaching, decision-making, and care planning. It ensures that interventions align with the client’s knowledge, values, and preferences at this critical stage.

A. Report of a chronic dull ache in the eyes B. Bilateral redness of the sclerae C. Increased opacity of the lens of the eye D. Report of seeing halos around lights

Correct Answer is C

Explanation

A. Report of a chronic dull ache in the eyes: Eye discomfort or ache is more commonly associated with conditions like glaucoma or eye strain. Cataracts are typically painless and do not produce chronic dull ache.

B. Bilateral redness of the sclerae: Redness of the sclera indicates inflammation or infection, such as conjunctivitis, and is not a characteristic sign of cataracts.

C. Increased opacity of the lens of the eye: Cataracts are defined by a clouding or opacity of the eye’s lens, which interferes with light transmission and vision. This physical change in the lens is the hallmark finding in cataract development.

D. Report of seeing halos around lights: Seeing halos is more commonly associated with glaucoma due to increased intraocular pressure, rather than cataracts. While cataracts may cause blurred or dim vision, halos are not the primary symptom.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A nurse delegates tasks to a licensed practical nurse (LPN) and an assistive personnel (AP). When admitting a client who is experiencing acute liver failure and who has ascites and an NG tube, which of the following tasks is most appropriate for the nurse to delegate to the LPN?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A home health nurse is conducting an initial home visit for a client who has terminal breast cancer. The client has two school-age children and a limited support system. Which of the following is the priority nursing action?

Correct Answer is D

Explanation

A nurse is performing a vision screening for a client. Which of the following findings should the nurse identify as an indication that the client has cataract?

Correct Answer is C

Explanation

A nurse is teaching a client who has a new prescription for digoxin. Which of the following statements should the nurse include in the teaching:

A nurse receives change-of-shift report. Which of the following clients should the nurse attend to first?

A nurse is assessing a client who has pneumococcal pneumonia. Which of the following findings should the nurse expect?

A nurse in an urgent care clinic is collecting admission history from a client who is at 16 weeks of gestation and has bacterial vaginosis. The nurse should recognize that which of the following clinical findings are associated with this infection?

A nurse is assessing laboratory values on a client who has taken an overdose of acetaminophen. The nurse should expect which of the following laboratory values indicative of organ damage from the overdose?

A nurse is preparing to discharge a client who is to be transferred to a long-term care facility. The nurse should recognize that which of the following actions is a breach of client confidentiality?

A nurse is caring for a client who has schizophrenia. The client states, "Run cats spin the rain throwing procedure mechanical paper lake." The nurse should document that the client is demonstrating which of the following speech alterations?

A nurse is caring for a school-age child who has celiac disease. Which of the following food choices should the nurse incorporate into the child's diet?