Exhibits

Select 4 interventions, assessments, and patient education strategies you would use to decrease the risk of a Healthcare-Associated Infection (HAI) for Mr. Johnson.

Choice A reason:

Instructing the client to hold a pillow to the abdominal incision when coughing is a task that involves patient education and reinforcement of postoperative care techniques. While LPNs/LVNs can provide basic patient education, this specific task requires ensuring that the patient understands the importance of splinting the incision to reduce pain and prevent complications such as wound dehiscence. This level of instruction is typically within the scope of practice for a registered nurse (RN), who has more extensive training in patient education and postoperative care. Therefore, this task is not the most appropriate for delegation to an LPN/LVN.

Choice B reason:

Obtaining bedside blood glucose is a task that is appropriate for delegation to an LPN/LVN. LPNs/LVNs are trained to perform routine tasks such as monitoring vital signs, including blood glucose levels, especially in patients with diabetes. This task involves using a glucometer to measure the patient’s blood sugar levels and recording the results. It does not require complex clinical judgment, making it suitable for an LPN/LVN. Regular monitoring of blood glucose is crucial for managing diabetes and preventing complications such as hyperglycemia or hypoglycemia.

Choice C reason:

Creating the plan of care is a complex task that involves comprehensive assessment, critical thinking, and clinical judgment. This task is typically within the scope of practice for an RN, who is trained to develop and implement individualized care plans based on a thorough assessment of the patient’s needs, medical history, and current condition. The RN collaborates with other healthcare team members to ensure that the care plan addresses all aspects of the patient’s recovery and health maintenance. LPNs/LVNs can contribute to the care plan by providing input and performing delegated tasks, but they do not have the authority to create the plan of care independently.

Choice D reason:

Documenting postoperative teaching involves recording the education provided to the patient about their postoperative care, including instructions on medication, activity restrictions, wound care, and signs of complications to watch for. This task requires ensuring that the patient understands the information and can follow the instructions correctly. While LPNs/LVNs can reinforce teaching and provide basic education, the initial comprehensive teaching and documentation are typically the responsibility of an RN. The RN ensures that the teaching is thorough and that the patient has the necessary knowledge to manage their care at home.

Choice A Reason: Fluid Volume Overload

Fluid volume overload, also known as hypervolemia, occurs when there is an excess of fluid in the body. This condition is often characterized by symptoms such as swelling (edema), shortness of breath, and high blood pressure. In the context of the patient’s scenario, fluid volume overload would typically present with signs like jugular venous distention, pulmonary congestion, and possibly ascites. The patient’s blood pressure is 109/70, which is not indicative of hypertension typically seen in fluid overload. Additionally, the patient’s lung sounds are clear, which further suggests that there is no pulmonary congestion. The lab results do not show a significant decrease in sodium levels, which might be expected in fluid overload due to dilutional hyponatremia.

Choice B Reason: Fluid Volume Deficit

Fluid volume deficit, or hypovolemia, is a condition where there is a significant loss of body fluids. This can result from severe diarrhea, as seen in the patient’s case. Symptoms of fluid volume deficit include lightheadedness, weakness, and muscle twitching, all of which the patient is experiencing. The patient’s blood pressure is on the lower side (109/70) and he gets lightheaded when standing up, indicating orthostatic hypotension, a common sign of fluid volume deficit. The elevated BUN (30 mg/dL) and creatinine (1.8 mg/dL) levels suggest dehydration and reduced kidney perfusion. The high potassium level (5.6 mEq/L) can be attributed to the body’s attempt to conserve water and sodium, leading to potassium retention. The ECG changes in the T wave and PR interval are consistent with hyperkalemia, which can occur in dehydration and kidney dysfunction.