A registered nurse (RN) and experienced licensed practical nurse (LPN) are caring for a group of clients. Which of the following is inappropriate for the RN to delegate to the LPN?

Choice A reason: Administering a tap-water enema is a skill within the scope of practice for an experienced LPN. This procedure is routine, does not require complex assessment, and can be safely delegated. The RN should ensure the LPN is competent in performing the task, but it is appropriate to delegate.

Choice B reason: Initiating a plan of care is a responsibility that requires comprehensive assessment, critical thinking, and clinical judgment. This task is reserved for the RN because it involves synthesizing data, setting priorities, and establishing individualized goals for the client. Delegating this to an LPN would be inappropriate, as LPNs can contribute to the plan but cannot independently initiate it.

Choice C reason: Catheterization of a client who has not voided in 8 hours is a technical skill that falls within the LPN’s scope of practice. LPNs are trained to perform catheterization safely, provided the RN has assessed the client and determined the need for the procedure. Therefore, this task can be delegated appropriately.

Choice D reason: Obtaining vital signs from a postoperative client is a routine task that LPNs can perform. Vital signs collection does not require advanced assessment skills, though interpretation of abnormal findings remains the RN’s responsibility. Delegating this task is appropriate and supports efficient workflow.

Choice A reason: Distended neck veins are a classic sign of fluid volume excess. Increased intravascular volume raises venous pressure, which manifests as jugular venous distension. This finding indicates that the circulatory system is overloaded and struggling to handle the excess fluid, often seen in conditions such as heart failure or renal impairment.

Choice B reason: Pitting edema in the lower extremities occurs when excess fluid accumulates in the interstitial spaces due to increased hydrostatic pressure. This is a hallmark of fluid overload, especially in older adults who may have compromised cardiac or renal function. Edema is a reliable indicator of systemic fluid retention.

Choice C reason: Crackles in the lungs upon auscultation are caused by fluid accumulation in the alveoli and interstitial spaces of the lungs. This pulmonary congestion is a direct consequence of fluid volume excess and can progress to pulmonary edema if untreated. Crackles are an important clinical sign that the excess fluid is affecting respiratory function.

Choice D reason: Swelling at the IV site is not an indicator of systemic fluid volume excess. Instead, it suggests localized infiltration or phlebitis at the IV insertion site. This is a complication of IV therapy but does not reflect overall fluid overload in the body.

Choice E reason: Urine specific gravity greater than 1.030 indicates concentrated urine, which is typically associated with dehydration rather than fluid volume excess. In fluid overload, urine may be more dilute due to increased renal excretion of water. Therefore, this finding does not support the diagnosis of fluid volume excess.