A nurse is planning client care for herself and an assistive personnel (AP) working with her. Which of the following tasks should the nurse plan to perform?
Assisting a client to cough and deep breathe
Application of antiembolic stockings
Administration of an enema
Assessing a client's sacrum for edema
The Correct Answer is D
Rationale:
A. Assisting a client to cough and deep breathe is a task that can be performed by an AP under supervision.
B. Application of antiembolic stockings is within the scope of APs, though it may be monitored by an RN.
C. Administration of an enema typically requires nursing judgment and assessment, making it more appropriate for the RN.
D. Assessing a client’s sacrum for edema requires clinical assessment skills and nursing judgment, which should be performed by an RN.
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Correct Answer is B
Explanation
Rationale:
A. Asking other staff nurses does not address the immediate concern of the client and could lead to gossip or unnecessary complications.
B. Addressing the concern with the specific staff nurse directly is appropriate to understand any issues and to see if there is a valid reason for the client’s request.
C. Recommending transfer without understanding the issue could be premature and might not address the root of the problem.
D. Notifying human resources is a step that may be needed later but should not be the first action; the manager should first address the issue with the staff nurse.
Correct Answer is D
Explanation
Rationale:
A. Measuring I&O is a task typically assigned to APs or RNs, not specifically requiring the LPN’s scope of practice.
B. Obtaining a client’s weight is a basic task that can be performed by APs.
C. Providing postmortem care can be performed by LPNs, but this task is not as complex as some others.
D. Inserting a nasogastric tube requires skills and knowledge specific to LPNs, making it an appropriate task for them.