A nurse is assigning client care to an RN and an LVN.
Which of the following tasks must they assign to an RN only and NOT to an LVN? All parts of the answer must be restricted to an RN only.
Creating a plan of care for a client who is recovering following a stroke.
Assessing a pressure injury on a client who is on bed rest.
Providing oral suctioning for a client who has pneumonia.
Administering internal feeding to a client who has a nasogastric tube.
Inserting a urinary catheter for a client who has urinary retention.
The Correct Answer is A
Choice A rationale
Creating a plan of care for a client recovering from a stroke requires comprehensive assessment, synthesis of complex data, and the establishment of nursing diagnoses and interventions. This falls within the scope of practice of a registered nurse who has the education and expertise in complex patient management.
Choice B rationale
Assessing a pressure injury involves observing and documenting wound characteristics. While an RN may perform this, an LVN, under the supervision of an RN, can also contribute to this task by collecting and reporting data about the wound.
Choice C rationale
Providing oral suctioning is a basic nursing skill that can be performed by both RNs and LVNs, following appropriate training and established protocols, to maintain airway patency for a client with pneumonia.
Choice D rationale
Administering internal feedings through a nasogastric tube is a task that can be delegated to an LVN who has received specific training and demonstrated competency, under the supervision of an RN, provided the client is stable and the feeding protocol is well-established.
Choice E rationale
Inserting a urinary catheter can be performed by both RNs and LVNs who have received the necessary education, training, and demonstrated competency in this invasive procedure, according to facility policies and state regulations.
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Correct Answer is A
Explanation
Choice A rationale
Before delegating any nursing task, the nurse must first determine if the action is permissible under the state's nurse practice act and the employing agency's policies. These regulations define the scope of practice for nurses and the tasks that can be safely and legally delegated to unlicensed personnel. If delegation is not allowed by these governing bodies, the subsequent questions become irrelevant.
Choice B rationale
While it is crucial to ensure that the UAP has been adequately trained and is competent to perform the delegated task safely and correctly, this consideration comes after establishing the legality and permissibility of the delegation according to the nurse practice act and agency policy. Training is important for safe implementation but not the initial determining factor.
Choice C rationale
Appropriate supervision is necessary when delegating tasks to UAPs to ensure client safety and provide guidance. However, the ability to delegate the task itself must first be established by legal and policy guidelines. Supervision is a component of safe delegation but not the primary question determining if delegation is even an option.
Choice D rationale
Evaluating the client's past response to a treatment might inform how the task is performed or any specific observations needed, but it does not determine the fundamental question of whether the task can be delegated to a UAP in the first place. Legal and policy frameworks dictate the scope of delegation, regardless of the client's history. .
Correct Answer is B
Explanation
Choice A rationale
Taking a sleeping pill at 9 pm might influence nighttime voiding indirectly by affecting sleep patterns or bladder awareness, but it doesn't directly increase urine production. Sleeping pills primarily work on the central nervous system to promote sleep and are not known to have a diuretic effect that would lead to increased nighttime urination.
Choice B rationale
Taking a diuretic at 7 pm significantly increases the risk of nocturia because diuretics promote fluid excretion by the kidneys. This increased urine production will likely occur during the night, after the medication has been absorbed and metabolized, leading to the need to wake up to urinate. The peak effect of many diuretics occurs within a few hours of administration.
Choice C rationale
Taking frequent naps during the day is unlikely to be a direct cause of nocturia. While changes in daytime activity and fluid intake patterns could indirectly influence nighttime voiding, napping itself does not have a physiological mechanism that directly increases urine production specifically at night.
Choice D rationale
Taking a diuretic at 7 am is less likely to cause nocturia compared to taking it in the evening. By 7 pm, the diuretic's effect of increased urine production will likely have subsided for most individuals, allowing for more normal bladder function during the night. The majority of the diuresis will occur during the daytime hours. .
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