A registered nurse (RN) and an experienced licensed practical nurse (LPN) are caring for a group of clients. Which of the following tasks should the RN delegate to the LPN? SELECT ALL THAT APPLY
Monitoring vital signs of postoperative clients.
Administering routine medications to stable clients.
Performing wound care on a client with a Stage III pressure ulcer.
Developing a teaching plan for a client newly diagnosed with Type II Diabetes.
Providing oral care to an unconscious client.
Correct Answer : A,B,C,E
Choice A reason:
Monitoring vital signs of postoperative clients is a task that can be safely delegated to an experienced LPN. LPNs are trained to monitor and report vital signs, which is a routine and essential part of postoperative care. This task does not require the advanced assessment skills of an RN, making it appropriate for delegation.
Choice B reason:
Administering routine medications to stable clients is within the scope of practice for LPNs. They are trained to administer medications and monitor clients for adverse reactions. As long as the clients are stable and the medications are routine, this task can be delegated to an LPN.
Choice C reason:
Performing wound care on a client with a Stage III pressure ulcer is a task that an experienced LPN can perform. LPNs are skilled in wound care and can manage complex dressings and treatments under the supervision of an RN. This delegation allows the RN to focus on more complex tasks that require their advanced skills.
Choice D reason:
Developing a teaching plan for a client newly diagnosed with Type II Diabetes is a task that should not be delegated to an LPN. This task requires comprehensive knowledge of diabetes management, patient education, and individualized care planning, which are within the RN’s scope of practice. The RN should develop the teaching plan and may involve the LPN in reinforcing the education.
Choice E reason:
Providing oral care to an unconscious client is a task that can be delegated to an experienced LPN. Oral care is essential for preventing infections and maintaining hygiene, and LPNs are trained to perform this care safely and effectively.
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Correct Answer is B
Explanation
Choice A reason:
Administering thrombolytics is not the first action the nurse should take. Thrombolytics are used to treat ischemic strokes, but their administration requires a thorough assessment and confirmation of the diagnosis through imaging studies. Immediate action is needed to ensure the client’s safety and initiate the stroke protocol.
Choice B reason:
Calling for help is the first action the nurse should take. The client is exhibiting signs of a possible stroke, and immediate medical intervention is required. Calling for help ensures that the stroke team or emergency response team is activated promptly to provide the necessary care.
Choice C reason:
Providing the client with water to test the gag reflex is not appropriate in this situation. The client may have difficulty swallowing, and giving water could lead to aspiration. The priority is to ensure the client’s safety and initiate the stroke protocol.
Choice D reason:
Performing carotid massage is not indicated for a client with new right-sided weakness and slurred speech. Carotid massage is used to manage certain types of arrhythmias, but it is not appropriate for suspected stroke. The focus should be on immediate assessment and intervention.
Correct Answer is C
Explanation
Choice A reason:
The Romberg test is not used to measure respiratory rate and depth. Respiratory assessments involve observing breathing patterns, rate, and depth, which are unrelated to the Romberg test.
Choice B reason:
While the Romberg test can provide some information about coordination, its primary purpose is not to evaluate fine motor skills. Fine motor skills are typically assessed through tasks that involve precise hand and finger movements.
Choice C reason:
The Romberg test is used to test for proprioception and vestibular function. It assesses the client’s ability to maintain balance with their eyes closed, which helps identify issues with proprioception (the sense of body position) and vestibular function (the inner ear’s role in balance).
Choice D reason:
The Romberg test does not assess cranial nerve function related to facial expression. Cranial nerve assessments involve specific tests for each nerve, such as asking the client to smile or raise their eyebrows to evaluate facial nerve function.