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 3 hr.
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 hr.
None
None
The Correct Answer is A
A. Inserting an indwelling urinary catheter is within the scope of practice of an LPN and is an appropriate task to delegate.
B. Measuring abdominal girth involves assessment of ascites progression, which requires the nurse’s judgment and should not be delegated.
C. Assessing and documenting the client’s level of consciousness requires critical nursing judgment and must be performed by the RN.
D. Measuring gastric drainage every 2 hr is an appropriate task for an AP, not specifically requiring an LPN.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Place the client's valuables in the facility's safe - While securing the client's valuables is important, it is not the priority upon admission.
B. Observe the client's level of mobility - This is the priority as it allows the nurse to assess the client's immediate physical condition and risk of falls or other mobility-related issues.
C. Administer prescribed medications - Medication administration can wait until the client's initial assessment, including mobility, has been completed.
D. Electronically enter the prescriptions from the provider - Entering prescriptions can be done after the initial assessment and immediate needs of the client have been addressed.
Correct Answer is D
Explanation
A. Prohibiting visitors is not necessary for clients with sealed internal radiation implants. Visitors should be allowed unless specific restrictions are required based on the type of radiation therapy.
B. While maintaining distance from the radiation source is important, there is no specific guideline stating a 3-foot distance. The nurse should follow institutional policies and radiation safety guidelines regarding proximity to the radiation source.
C. There is no need to maintain the client on bed rest for 72 hours after receiving a sealed
internal radiation device. The client should be encouraged to ambulate and perform activities of daily living as tolerated.
D. Requiring the client to wear a dosimeter badge allows healthcare providers to monitor the amount of radiation exposure received by the client and ensures that radiation safety protocols are followed.
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
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.
