Nokea
The nurse is delegating unit nursing tasks for the day. Which tasks should the nurse delegate to the unlicensed assistive personnel (UAP)? Select all that apply.
- A. Deliver fresh water to clients.
- B. Empty urine out of Foley bags.
- C. Take temperatures, pulses, respirations, and blood pressures.
- D. Count the substance control medications in the opioid medication supply.
- E. Check the crash cart (cardiopulmonary resuscitation cart) for necessary supplies using a checklist.
- F. Check all intravenous (IV) solution bags on clients receiving IV therapy for the remaining amounts of solution in the bags.
Correct Answer: A,B,C
Rationale: Delegation is the transfer of responsibility for the performance of an activity or task while retaining accountability for the outcome. When delegating an activity, the nurse must consider the educational preparation and experience of the individual. The UAP is trained to perform noninvasive tasks and those that meet basic client needs. The UAP is also trained to take vital signs. Therefore, the appropriate activities to assign to the UAP would be to deliver fresh water to clients; empty urine out of Foley bags; and take temperatures, pulses, respirations, and blood pressures. Although the UAP is trained in performing cardiopulmonary resuscitation, the UAP is not trained to check a crash cart, and this activity must be assigned to a licensed nurse. Any activities related to medications and IV therapy must be delegated to a licensed nurse.
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The client with a diagnosis of bladder cancer is to undergo weekly intravesical chemotherapy for the next 8 weeks. Which statement by the client should indicate to the nurse that the client understands how to manage urine as a biohazard?
- A. Void into a bedpan and then empty the urine into the toilet.
- B. Purchase extra bottles of scented disinfectant for daily bathroom cleansing.
- C. Have one bathroom strictly set aside for the client's use for the next 8 weeks.
- D. Disinfect the toilet with household bleach after voiding for 6 hours after a treatment.
Correct Answer: D
Rationale: Intravesical instillation involves instilling a chemotherapeutic agent into the bladder via a urethral catheter. This method of treatment provides a concentrated topical treatment with minimal systemic absorption. The client retains the medication for approximately 2 hours. After intravesical chemotherapy, the client treats the urine as a biohazard. This involves disinfecting the toilet after voiding with household bleach for 6 hours after a treatment. There is no value in using a bedpan for voiding. Scented disinfectants are of no particular use. The client does not need to have a separate bathroom for personal use.
A registered nurse (RN) in charge of the client care unit is preparing the assignments for the day. The RN assigns unlicensed assistive personnel (UAP) to make beds and bathe one of the clients on the unit and assigns additional UAP to fill the water pitchers and serve juice to all of the clients. Another RN is assigned to administer all medications. Based on the assignments designed by the RN in charge, which nursing care delivery model is being implemented?
- A. Team
- B. Primary
- C. Functional
- D. Exemplary
Correct Answer: C
Rationale: The functional model of care involves an assembly line approach to client care, with major tasks being delegated by the charge nurse to individual staff members. Team nursing is characterized by a high degree of communication and collaboration among members. The team is generally led by an RN, who is responsible for assessing, developing nursing diagnoses, planning, and evaluating each client's plan of care. In primary nursing, concern is with keeping the nurse at the bedside actively involved in care, providing goal-directed and individualized client care. In an exemplary model of team nursing, each staff member works fully within the realm of educational and clinical experience in an effort to provide comprehensive individualized client care. Each staff member is accountable for client care and outcomes of care.
During the admission process of a client being admitted for surgery, the client asks the nurse if a living will, prepared 3 years ago, remains in effect. Which response is most appropriate for the nurse to provide the client?
- A. Yes, a living will never expires.
- B. You need to speak with an attorney.
- C. I will call someone to answer your question.
- D. If it accurately reflects your situation and wishes.
Correct Answer: D
Rationale: The client should discuss the living will with the primary health care provider (HCP) on a regular basis to ensure that it contains the client's current wishes and desires based on the client's current health status. Option 1 is incorrect. Although the client can consult an attorney if the living will must be changed, the accurate nursing response is to tell the client that a living will should be reviewed. Option 3 is not at all helpful to the client and is, in fact, a communication block and places the client's question on hold.
The nurse is planning care for a suicidal client who is hallucinating and delusional. Which intervention should the nurse incorporate into the nursing care plan to best assure client safety?
- A. Check the client's location every 15 minutes.
- B. Begin suicide precautions with 30-minute checks.
- C. Initiate one-to-one suicide precautions immediately.
- D. Ask the client to report suicidal thoughts immediately.
Correct Answer: C
Rationale: One-to-one suicide precautions are required for the client rescued from a suicide attempt. In this situation, additional significant information is that the client is delusional and hallucinating. Both of these factors increase the risk of unpredictable behavior, compromised judgment, and the risk of suicide. Options 1, 2, and 4 do not provide the constant supervision necessary for this client.
The nurse instructs a client with a diagnosis of atrial fibrillation who has been prescribed warfarin to use an electric razor for shaving. Which premise best supports the rationale for this instruction?
- A. Cuts need to be avoided.
- B. Any cut may cause infection.
- C. Electric razors can be disinfected.
- D. All straight razors contain bacteria.
Correct Answer: A
Rationale: Clients with atrial fibrillation are placed on anticoagulants to prevent thrombus formation and possible stroke. Therefore, measures to prevent bleeding need to be taught to the client. The importance of use of an electric razor is to prevent cuts and possible bleeding. Not all cuts cause infection. Electric razors can be cleaned but usually cannot be disinfected. Not all straight razors contain bacteria. Additionally, options 2, 3, and 4 are all unrelated to the subject of bleeding; rather, they relate to infection.