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A client is admitted with a lower urinary tract infection from an obstructing ureteral stone. Which tasks can the nurse delegate to the experienced unlicensed assistive personnel? Select all that apply.
- A. Collecting a urine specimen for culture and sensitivity
- B. Frequent turning and repositioning of the client
- C. Measuring and documenting urine output
- D. Monitoring the color and characteristics of urine output
- E. Teaching the client to strain urine while voiding
Correct Answer: B,C
Rationale: Turning and measuring output are within UAP scope. Collecting specimens , monitoring characteristics , and teaching require nursing judgment.
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During the interview of a prospective employee who just completed the agency orientation, which approach would be the best for the nurse manager to use to assess competence?
- A. What degree of supervision for basic care do you think you need?
- B. Let's review your skills check-list for type and level of skill
- C. Are you comfortable working independently?
- D. What client care tasks or assignments do you prefer?
Correct Answer: B
Rationale: The nurse needs to know that the employee has competence in certain tasks. One way to do this is to do mutual review of documented skills.
The nurse is caring for a 10-year-old client with osteomyelitis. Which of the following actions should the nurse take to promote age-appropriate growth and development during hospitalization?
- A. Ask the parent to bring schoolwork for the client to complete
- B. Encourage the client to engage in imaginary play with animal puppets
- C. Explain procedures to the client immediately before they are performed
- D. Provide opportunities for the client to play independently
Correct Answer: A
Rationale: Schoolwork supports cognitive development for a 10-year-old. Imaginary play suits younger children, last-minute explanations increase anxiety, and independent play may not meet social needs.
The licensed practical nurse is assisting the charge nurse in planning care for a client with a detached retina. Which of the following nursing diagnoses should receive priority?
- A. Alteration in comfort
- B. Alteration in mobility
- C. Alteration in skin integrity
- D. Alteration in O2 perfusion
Correct Answer: B
Rationale: Alteration in mobility is priority for a detached retina, as positioning and activity restrictions prevent further detachment. Comfort, skin integrity, and O2 perfusion are secondary concerns.
Which of the following tasks can the nurse assign to an unlicensed assistive personnel (UAP)?
- A. assisting a client with ambulating to the bathroom for the first time following surgery
- B. expiated client with dementia who has a serum glucose level of 70 mg/dL (3.9 mmol/L)
- C. explaining why incentive spirometer use is important to a client with postoperative pneumonia
- D. taking vital signs every 15 minutes on a client who was just transferred from the postanesthesia recovery unit
Correct Answer: D
Rationale: Taking vital signs is within UAP scope. First-time ambulation , hypoglycemia , and teaching require nursing judgment.
The hospital nurse administers CPR to an adult male who is found unconscious, has no pulse, and is not breathing. What is the ratio of chest compressions to respirations for one-person rescue?
- A. Fifteen chest compressions to one breath
- B. Fifteen chest compressions to two breaths
- C. Thirty chest compressions to two breaths
- D. Thirty chest compressions to two breaths
Correct Answer: C
Rationale: Current CPR guidelines recommend 30 chest compressions to 2 breaths for one-person adult resuscitation, optimizing circulation and oxygenation.