A nurse is preparing to discharge a client who requires home oxygen. The equipment company has not yet delivered the oxygen tank. Which of the following actions should the nurse take?

Rationale:
A. Documentation in the incident report should be objective and factual, but the phrase “Entered room and discovered client lying prone on the floor” is somewhat narrative and includes unnecessary detail about the nurse’s actions rather than the client’s condition.

B. Including statements about the incident report in the nurse’s notes is inappropriate. Incident reports are separate legal documents and should not be referenced in the medical record to avoid legal implications.

C. Documenting in the incident report that the client was found lying on the floor after falling out of bed is objective, factual, and concise, which is appropriate for incident reporting. It clearly communicates the event without including speculation, blame, or unnecessary detail.

D. Writing “Incident report completed and filed” in the nurse’s notes is not appropriate. The nurse’s notes should focus on the client’s condition, assessment findings, and care provided, not the completion of the incident report.

Rationale:

A. Administering a hepatitis B vaccine is within the scope of practice for an LPN. LPNs are trained and licensed to administer routine injections and vaccines, monitor for immediate adverse reactions, and document administration. This task does not require the higher-level assessment skills of an RN, making it appropriate for delegation. Administering immunizations to newborns is a standard, routine intervention that aligns with an LPN’s responsibilities under RN supervision.

B. Conducting a newborn hearing screening involves specialized assessment techniques and interpretation of results. This task is typically performed by a trained RN, audiologist, or certified hearing screener, as it requires advanced assessment skills and understanding of neonatal hearing protocols. Assigning this to an LPN is inappropriate.

C. Performing a New Ballard assessment (used to determine gestational age) requires advanced neonatal assessment skills, including observation of neuromuscular and physical maturity signs. This is a competency reserved for RNs or clinicians trained in neonatal assessments and is beyond the typical LPN scope of practice.

D. Obtaining vital signs is a basic nursing task that can be delegated to an assistive personnel (AP). APs are competent to measure and record temperature, heart rate, respiratory rate, and blood pressure, freeing RNs and LPNs to perform tasks that require more skill and clinical judgment.