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","B","C","D"]
Explanation
Choice A reason: Checking the drainage bag level ensures it’s below the abdomen to promote gravity-dependent outflow. This addresses reduced outflow in peritoneal dialysis, making it a correct action the nurse would take to resolve the inflow-outflow discrepancy safely.
Choice B reason: Repositioning to the side can dislodge catheter obstructions or improve drainage in peritoneal dialysis. This is a standard intervention for low outflow, making it a correct action the nurse would perform to correct the client’s dialysis flow issue.
Choice C reason: Good body alignment prevents catheter kinking and promotes effective drainage in peritoneal dialysis. This addresses outflow issues, making it a correct action the nurse would take to ensure proper function of the dialysis system for the client.
Choice D reason: Checking for kinks in the dialysis system identifies mechanical causes of reduced outflow. This is a key troubleshooting step, making it a correct action the nurse would perform to resolve the inflow-outflow imbalance in the client’s peritoneal dialysis.
Choice E reason: Contacting the provider is premature before troubleshooting mechanical issues like kinks or positioning. Checking the drainage bag is a priority, making this incorrect, as it delays the nurse’s initial actions to correct the dialysis outflow problem independently.
Choice F reason: Increasing the flow rate doesn’t address outflow obstruction and may worsen fluid imbalance. Repositioning is more appropriate, making this incorrect, as it’s not a safe action compared to the nurse’s focus on resolving mechanical dialysis issues first.
Correct Answer is B
Explanation
Choice A reason: A beefy red, shiny stoma is normal, indicating healthy tissue perfusion. Purple discoloration suggests ischemia, making this incorrect, as it doesn’t require immediate notification compared to the nurse’s priority of reporting a potentially life-threatening stoma complication to the provider.
Choice B reason: Purple discoloration of the stoma indicates potential ischemia or necrosis, a serious complication requiring immediate provider notification. This aligns with colostomy care priorities, making it the correct observation for the nurse to report promptly to prevent further tissue damage or obstruction.
Choice C reason: Skin excoriation around the stoma is concerning but less urgent than purple discoloration, which signals ischemia. This is incorrect, as it can be managed with barrier creams, unlike the nurse’s priority of addressing a critical stoma issue requiring immediate intervention.
Choice D reason: Semiformed stool in the ostomy pouch is expected post-colostomy and not alarming. Purple discoloration is critical, making this incorrect, as it’s a normal finding compared to the nurse’s need to notify the provider about a potentially ischemic stoma.
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