The practical nurse (PN) observes a client’s initial postoperative dressing, which is saturated with serosanguinous fluid, and a drainage device that appears partially compressed. Which follow-up actions should the PN implement? (Select all that apply.).

The correct answer is choice D - Bilateral lung sounds.

Choice A rationale:

Heart sounds. While assessing heart sounds is crucial, the question specifically mentions complications of left-sided heart failure, which primarily affects the lungs. Therefore, assessing lung sounds is a higher priority in this situation.

Choice B rationale:

Mood and affect. While assessing the client's mood and affect is important for holistic care, it is not the most critical assessment to implement first in the case of left-sided heart failure complications.

Choice C rationale:

Chest pain. Although chest pain may be a symptom of left-sided heart failure complications, assessing bilateral lung sounds takes precedence as it directly relates to the client's respiratory status.

Choice D rationale:

Bilateral lung sounds. In left-sided heart failure, fluid can accumulate in the lungs, leading to pulmonary congestion and impaired gas exchange. Therefore, assessing lung sounds helps identify any respiratory distress early on, allowing prompt intervention and prevention of further complications.

The correct answer is **b. Oral feeding of a two-year-old child after application of a hip spica cast.**

Choice A rationale:

Participation in staff rounds to record notes regarding client goals is not an appropriate task to delegate to a UAP. This task requires clinical assessment, judgment, and documentation skills that are within the scope of practice of a licensed practical nurse (PN), but not a UAP.

Choice B rationale:

Oral feeding of a two-year-old child after application of a hip spica cast is an appropriate task that the PN can delegate to a UAP. Feeding a stable patient is a routine task that does not require advanced nursing skills or clinical judgment. As long as the child is not at high risk for complications, this task can be safely delegated to a UAP with proper training and supervision.

Choice C rationale:

Evaluation of a client's incisional pain following narcotic administration is not an appropriate task to delegate to a UAP. This task requires clinical assessment, evaluation of medication effects, and critical thinking skills that are within the scope of practice of a PN, but not a UAP.

Choice D rationale:

Assessment of the placement and patency of a nasogastric feeding tube is not an appropriate task to delegate to a UAP. This task requires specialized nursing skills and clinical judgment to ensure the safety and effectiveness of the feeding tube. It is within the scope of practice of a PN, but not a UAP.