After undergoing a modified radical mastectomy, a client is transferred to the PACU. Which nursing action is best to delegate to an experienced LPN/LVN?

After undergoing a modified radical mastectomy, a client is transferred to the PACU. Which nursing action is best to delegate to an experienced LPN/LVN?

• A. Documenting the initial assessment on the client's chart
• B. Teaching the client about the importance of using pain medication as needed
• C. Monitoring the client's dressing for any signs of bleeding
• D. Communicating the client's status report to the charge nurse on the surgical unit

Answer: (C)

The key idea is matching tasks to scope of practice while keeping patient safety at the forefront. In the immediate post-op PACU period, the most crucial ongoing responsibility is detecting changes in the surgical site and dressing that could signal bleeding. An experienced LPN/LVN is well suited to routinely monitor the dressing for signs of bleeding, check drainage, and report any changes promptly to the registered nurse. This type of ongoing surveillance is within an LPN/LVN’s scope and does not require the initial, comprehensive assessment or patient-teaching that belong to the RN. Teaching the patient about pain medication and delivering a status report directly to the charge nurse involve higher-level assessment, education, or leadership tasks that are typically reserved for the RN.

The key idea is matching tasks to scope of practice while keeping patient safety at the forefront. In the immediate post-op PACU period, the most crucial ongoing responsibility is detecting changes in the surgical site and dressing that could signal bleeding. An experienced LPN/LVN is well suited to routinely monitor the dressing for signs of bleeding, check drainage, and report any changes promptly to the registered nurse. This type of ongoing surveillance is within an LPN/LVN’s scope and does not require the initial, comprehensive assessment or patient-teaching that belong to the RN. Teaching the patient about pain medication and delivering a status report directly to the charge nurse involve higher-level assessment, education, or leadership tasks that are typically reserved for the RN.