A nurse enters a client's room and finds the client pulseless. The family has requested a do-not-resuscitate (DNR) order from the provider, but he has not written the order yet. Which of the following actions should the nurse take?

Rationale:

A. Palpate for possible bladder distention is a task that requires nursing assessment skills and should be done by the nurse.

B. Observe the incision site is a nursing task that involves assessing for signs of complications.

C. Change the abdominal dressing requires sterile technique and should be done by a nurse to prevent infection and ensure proper care.

D. Obtain vital signs is within the AP’s scope of practice and is a task that can be delegated. It is important for monitoring the client’s status and identifying potential issues.

Rationale:

A. Agency policies for the LPN are important but secondary to ensuring the tasks fall within the scope of practice.

B. The documented experience level of the LPN is relevant but should be considered in conjunction with the scope of practice.

C. The documented skill level of the LPN is important for assigning tasks but must align with legal scope of practice.

D. State Nurse Practice Act for the LPN is the priority criterion as it defines the legal scope of practice and ensures that tasks delegated to the LPN are within their legal and professional boundaries.