A nurse is following protocol for preventing puncture injuries. Which of the following actions should the nurse take?

A. Inserting an indwelling catheter involves an invasive procedure and assessment of urinary output and client status, which falls within the RN’s scope of practice in a high-risk client such as one with acute liver failure.

B. Obtaining abdominal girth requires assessment skills and interpretation for changes in ascites, which is more appropriate for the RN to ensure accurate monitoring.

C. Assessing and documenting level of consciousness is a critical assessment, especially in liver failure where hepatic encephalopathy is a risk. This is within the RN’s responsibility because changes can be subtle and require immediate intervention.

D. Measuring the amount of gastric drainage every 2 hours is a stable, routine task that follows established parameters and does not require advanced assessment skills. It is within the LPN’s scope and can be safely delegated, with the RN overseeing interpretation of any abnormal findings.

A. A blood glucose level of 120 mg/dL is within the expected range for a client receiving total parenteral nutrition and does not require immediate intervention.

B. A serum sodium level of 138 mEq/L is within the normal range and does not require immediate intervention.

C. An oral temperature of 37.6°C (99.7°F) is slightly elevated but may be within the client's normal range and does not require immediate intervention unless accompanied by other signs of infection.

D. A weight increase of 2 kg (4.4 lb) in the past 24 hours indicates fluid overload, which can lead to complications such as heart failure or pulmonary edema. Immediate intervention, such as adjusting the rate of fluid administration or notifying the healthcare provider, is necessary to prevent further complications.