A registered nurse (RN) and an experienced licensed practical nurse (LPN) are caring for a group of clients. Which of the following tasks should the RN delegate to the LPN? SELECT ALL THAT APPLY
Initiate a plan of care for a client who is postoperative from an appendectomy.
Administer a tap-water enema to a client who is preoperative.
Provide discharge instructions to a confused client's spouse.
Catheterize a client who has not voided in 8 hours.
Obtain vital signs from a client who is 6 hours postoperative.
Correct Answer : B,D,E
Choice A reason: Initiating a plan of care for a client who is postoperative from an appendectomy is not a task that the RN should delegate to the LPN, as it requires nursing judgment, critical thinking, and assessment skills that are beyond the scope of practice of the LPN. The RN is responsible for developing, implementing, and evaluating the plan of care for each client based on their individual needs, preferences, and goals. The RN can delegate some aspects of the plan of care to the LPN, such as performing routine tasks or monitoring the client's status, but the RN must supervise and evaluate the LPN's performance.
Choice B reason: Administering a tap-water enema to a client who is preoperative is a task that the RN can delegate to the LPN, as it is a standardized procedure that does not require nursing judgment or assessment. The LPN has the knowledge and skills to perform this task safely and effectively, following the established policies and protocols of the facility. The RN should provide clear instructions and expectations to the LPN, such as the type, amount, and temperature of the solution, the position and comfort of the client, and the signs and symptoms to report. The RN should also verify that the LPN has completed the task and documented the outcome.
Choice C reason: Providing discharge instructions to a confused client's spouse is not a task that the RN should delegate to the LPN, as it involves teaching, counseling, and evaluating the client's and family's understanding and readiness for discharge. These are complex activities that require nursing judgment, communication skills, and evaluation skills that are beyond the scope of practice of the LPN. The RN is responsible for ensuring that the client and family receive adequate information and education about the client's condition, treatment, medications, follow-up care, and community resources. The RN can delegate some aspects of discharge planning to the LPN, such as collecting data or providing reinforcement of teaching, but the RN must supervise and evaluate the LPN's performance.
Choice D reason: Catheterizing a client who has not voided in 8 hours is a task that the RN can delegate to the LPN, as it is a standardized procedure that does not require nursing judgment or assessment. The LPN has the knowledge and skills to perform this task safely and effectively, following the established policies and protocols of the facility. The RN should provide clear instructions and expectations to the LPN, such as the type and size of the catheter, the sterile technique, and the urine output measurement. The RN should also verify that the LPN has completed the task and documented the outcome.
Choice E reason: Obtaining vital signs from a client who is 6 hours postoperative is a task that the RN can delegate to the LPN, as it is a routine task that does not require nursing judgment or assessment. The LPN has the knowledge and skills to perform this task safely and effectively, using appropriate equipment and techniques. The RN should provide clear instructions and expectations to the LPN, such as the frequency and parameters of vital signs monitoring. The RN should also verify that the LPN has completed the task and documented the outcome.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Giving the patient extra time to perform activities is an appropriate action by the nurse. Bradykinesia is a symptom of Parkinson's disease that causes slow and reduced movement, making it difficult for the patient to initiate and complete tasks. The nurse should respect the patient's autonomy and dignity, and allow them to do as much as they can by themselves, without rushing or interfering.
Choice B reason: Teaching the client to walk more quickly when ambulating is not an appropriate action by the nurse. Bradykinesia can affect the patient's gait and balance, making them prone to falls and injuries. The nurse should not encourage the patient to walk faster than their ability, but rather provide them with assistive devices, such as a cane or walker, and ensure a safe environment.
Choice C reason: Placing the client on a low-protein, low-calorie diet is not an appropriate action by the nurse. Bradykinesia does not require any specific dietary modifications, unless the patient has other comorbidities, such as diabetes or hypertension. The nurse should ensure that the patient has adequate nutrition and hydration, and avoid foods that may interfere with their medication absorption, such as high-fiber or high-fat foods.
Choice D reason: Completing passive range-of-motion exercises daily is not an appropriate action by the nurse. Bradykinesia can cause muscle stiffness and rigidity, which can limit the patient's range of motion and flexibility. The nurse should encourage the patient to do active range-of-motion exercises, which involve moving their own joints to their full extent, rather than passive ones, which involve someone else moving their joints for them. Active exercises can help maintain muscle strength and joint mobility and prevent contractures and deformities.
Correct Answer is C
Explanation
Choice A reason: "Diet and exercise is good for you and good for your heart." This statement is true, but it is not the appropriate nursing response. It does not address the client's concerns or provide any specific information about cardiac rehabilitation. It may also sound dismissive or patronizing to the client.
Choice B reason: "It's not unusual to feel that way at first, but once you learn the routine, you'll enjoy it." This statement is empathetic, but it is not the appropriate nursing response. It does not explain the purpose or benefits of cardiac rehabilitation. It may also sound unrealistic or optimistic to the client.
Choice C reason: "Cardiac rehabilitation cannot undo the damage to your heart, but it can help you get back to your previous level of activity safely." This statement is the appropriate nursing response. It acknowledges the client's condition and provides factual information about cardiac rehabilitation. It also emphasizes the positive outcomes of cardiac rehabilitation, such as improving physical function, reducing symptoms, and preventing further complications.
Choice D reason: "Your doctor is the expert here, and I'm sure he would only recommend what is best for you." This statement is respectful, but it is not the appropriate nursing response. It does not answer the client's question or provide any education about cardiac rehabilitation. It may also sound evasive or deferential to the client.
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