Which information will the nurse consider when deciding what nursing actions to delegate to a licensed practical/vocational nurse (LPN/VN) who is working on a medical-surgical unit?

Choice A: Promote healing by increasing the rate of the muscle remodeling process

While heat can aid in the healing process by improving blood flow and nutrient delivery to the injured area, it does not specifically increase the rate of the muscle remodeling process. Muscle remodeling involves complex cellular activities that are not solely influenced by external heat application.

Choice B: Decrease pain by reducing inflammation

Heat therapy is generally not used to reduce inflammation. In fact, applying heat to an inflamed area can sometimes exacerbate the inflammation. Cold therapy is more effective for reducing inflammation, especially in the initial stages of an injury.

Choice C: Decrease pain by increasing circulation to a painful area and relaxing tense muscles

This is the correct answer. Applying heat to a painful area causes vasodilation, which increases blood flow and helps deliver oxygen and nutrients to the affected tissues. This process helps to relax tense muscles and alleviate pain. Heat therapy is particularly effective for muscle spasms, stiffness, and chronic pain conditions.

Choice D: Decrease pain by numbing pain signals

Heat therapy does not numb pain signals in the same way that cold therapy does. Cold therapy works by numbing the affected area and reducing nerve activity, which helps to alleviate pain. Heat therapy, on the other hand, works by improving circulation and relaxing muscles.

Choice A reason:

Monitoring for shortness of breath or fatigue after ambulation is a critical task that requires clinical judgment and assessment skills. Certified Nurse Assistants (CNAs) are trained to assist with basic patient care activities but are not typically trained to assess and interpret clinical symptoms such as shortness of breath or fatigue. These symptoms could indicate serious complications such as pulmonary embolism or cardiac issues, which require immediate attention from a licensed nurse or physician. Therefore, this task is not appropriate for delegation to a CNA.

Choice B reason:

Determining whether the patient is ready to increase activity involves assessing the patient’s overall condition, including their vital signs, pain levels, and physical capabilities. This requires a comprehensive understanding of the patient’s medical history and current status, which falls within the scope of practice of a registered nurse (RN) or licensed practical nurse (LPN). CNAs do not have the training to make such determinations, as it involves critical thinking and clinical decision-making skills. Therefore, this task should not be delegated to a CNA.

Choice C reason:

Obtaining the patient’s blood pressure and pulse rate after ambulation is a task that is appropriate for delegation to a CNA. CNAs are trained to measure and record vital signs, including blood pressure and pulse rate. This task does not require clinical judgment or decision-making, making it suitable for delegation. The CNA can report the findings to the nurse, who can then interpret the results and make any necessary clinical decisions. This delegation allows the nurse to focus on more complex tasks that require their advanced training and expertise.

Choice D reason:

Instructing the patient on how to use an incentive spirometer involves patient education, which is a responsibility that typically falls to licensed nurses. Proper use of an incentive spirometer is crucial for preventing postoperative complications such as atelectasis and pneumonia. Ensuring that the patient understands how to use the device correctly requires not only demonstrating its use but also assessing the patient’s comprehension and ability to perform the task. This level of patient education and assessment is beyond the scope of practice for a CNA.