A nurse is delegating tasks to a team of staff members for a 65-year-old female patient who is post-op day 1 following a total knee replacement. The patient has stable vital signs (BP 130/85, HR 78 bpm, RR 18) and is ambulating with assistance. The nurse is considering delegating tasks to the LPN. Which of the following tasks can the nurse safely delegate to the LPN?
Assisting the patient with ambulation and evaluating pain level.
Administering prescribed medication and monitoring for side effects.
Performing a full head-to-toe assessment and identifying any complications.
Educating the patient on discharge instructions for post-operative care.
The Correct Answer is B
Choice A reason: Evaluating pain level requires RN judgment, though assisting with ambulation is within the LPN’s scope. Medication administration is fully delegable, making this incorrect, as it includes an assessment task beyond the LPN’s role in post-operative care.
Choice B reason: Administering prescribed medication and monitoring for side effects is within the LPN’s scope, ensuring safe delegation. This aligns with post-operative care protocols, making it the correct task the nurse can safely delegate to the LPN for the knee replacement patient.
Choice C reason: A full head-to-toe assessment and identifying complications require RN expertise, exceeding LPN scope. Medication administration is appropriate, making this incorrect, as it’s an improper delegation for the nurse to assign to the LPN post-surgery.
Choice D reason: Educating on discharge instructions involves teaching and evaluation, an RN responsibility. Administering medication is within LPN scope, making this incorrect, as it’s not a safe task for the nurse to delegate to the LPN for the patient.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C","D"]
Explanation
Choice A reason: Administering oxygen improves oxygenation in air embolism, addressing hypoxia from chest pain and shortness of breath. This aligns with emergency dialysis protocols, making it a correct priority action the nurse would take to stabilize the client’s condition.
Choice B reason: Continuing dialysis, even slowly, risks worsening air embolism by introducing more air. Stopping dialysis is critical, making this incorrect, as it’s unsafe compared to the nurse’s priority of halting the procedure to prevent further embolism complications.
Choice C reason: Notifying the provider and Rapid Response Team ensures rapid intervention for air embolism, a life-threatening dialysis complication. This aligns with emergency protocols, making it a correct priority action the nurse would take to manage the client’s acute condition.
Choice D reason: Stopping dialysis and positioning the client on the left side with head down traps air in the right atrium, preventing pulmonary embolism. This is a standard intervention, making it a correct priority action for the nurse to address air embolism.
Choice E reason: Bolusing 500 mL saline doesn’t break up air emboli and risks fluid overload in kidney disease. Oxygen administration is appropriate, making this incorrect, as it’s ineffective compared to the nurse’s priority actions for managing air embolism.
Correct Answer is B
Explanation
Choice A reason: Shortness of breath is a heart failure symptom, not a furosemide side effect, which causes diuresis. Lightheadedness from hypotension is common, making this incorrect, as it confuses disease symptoms with medication effects in the nurse’s monitoring plan for furosemide.
Choice B reason: Lightheadedness is a common furosemide adverse effect due to hypotension or electrolyte imbalances from diuresis. This aligns with pharmacological monitoring for heart failure treatment, making it the correct effect the nurse should plan to monitor in the client.
Choice C reason: Dry cough is associated with ACE inhibitors, not furosemide, a diuretic causing hypotension. Lightheadedness is a furosemide effect, making this incorrect, as it misattributes a side effect to the wrong medication in the nurse’s monitoring for heart failure treatment.
Choice D reason: Bitter taste is not a typical furosemide side effect; it’s more linked to medications like antibiotics. Lightheadedness is relevant, making this incorrect, as it does not reflect the expected adverse effects the nurse should monitor with furosemide administration.
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