A nurse delegates tasks to a licensed practical nurse (LPN) and an assistive personnel (AP).
When admitting a client who is experiencing acute liver failure and who has ascites and an NG tube, which of the following tasks is most appropriate for the nurse to delegate to the LPN?
A.
Insert an indwelling catheter if the client has not voided in 3 hr.
B.
Obtain the abdominal girth now and every 4 hr.
C.
Assess and document the level of consciousness every hour.
D.
Measure the amount of gastric drainage every 2 hr.
The Correct answer and Explanation is:
The correct answer is D. Measure the amount of gastric drainage every 2 hr.
Explanation:
When delegating tasks within a healthcare team, it is crucial to consider the scope of practice for each role and the complexity of the tasks involved. In this scenario, the nurse is working with a client who has acute liver failure, ascites, and an NG tube, necessitating careful monitoring and specific interventions.
A. Insert an indwelling catheter if the client has not voided in 3 hr.
This task requires a higher level of nursing judgment and assessment skills. While LPNs can perform catheterizations, the situation involving acute liver failure may necessitate assessment of underlying issues such as fluid balance and renal function, which a registered nurse (RN) should evaluate.
B. Obtain the abdominal girth now and every 4 hr.
Measuring abdominal girth is important in assessing ascites but requires ongoing assessment and clinical judgment about changes that may necessitate immediate nursing intervention. This task may be better suited for the RN.
C. Assess and document the level of consciousness every hour.
This task is complex, as it requires critical thinking and a comprehensive understanding of neurological changes. Given the client’s acute liver failure, changes in consciousness may indicate hepatic encephalopathy, requiring immediate intervention from the RN.
D. Measure the amount of gastric drainage every 2 hr.
This task is appropriate for delegation to an LPN. LPNs are trained to monitor and document the output from NG tubes, which is a routine and straightforward task. Measuring gastric drainage is essential for evaluating the client’s fluid status and nutritional needs, and it does not require the RN’s level of assessment skills.
In summary, while all options relate to the client’s care, option D is the most appropriate task to delegate to the LPN, as it falls within their scope of practice and does not require complex assessment or critical thinking that is essential for the RN’s role in managing the client’s overall condition.