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

Answer and Explanation

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.

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Correct Answer is A

Explanation

A. Hallucinations - Delirium can cause perceptual disturbances such as hallucinations, where the client perceives things that are not actually present.

B. Agnosia - Agnosia refers to the inability to recognize familiar objects, which is not typically associated with delirium.

C. Bradycardia - Delirium is not typically associated with bradycardia; it may actually be associated with tachycardia due to the physiological stress response.

D. Aphasia - Aphasia refers to the loss of ability to understand or express speech, which is not typically associated with delirium.

A. "I will take this medication within 15 minutes of eating." B. "I will take this medication at bedtime." C. "I will take this medication with 8 ounces of water." D. "I will increase my caffeine intake while taking this medication."

Correct Answer is C

Explanation

A. Alendronate should be taken on an empty stomach, preferably in the morning, and the client should wait at least 30 minutes before eating or drinking anything other than water.

B. Alendronate should be taken in the morning, not at bedtime, to reduce the risk of esophageal irritation and ensure proper absorption.

C. Taking alendronate with 8 ounces of water helps facilitate proper absorption and reduces the risk of esophageal irritation.

D. Increasing caffeine intake while taking alendronate is not recommended, as caffeine can interfere with calcium absorption and potentially worsen osteoporosis.

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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?

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Correct Answer is A

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Correct Answer is C

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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?