Nokea
A nurse who works in a long-term care facility is delegating aspects of client care to unlicensed assistive personnel (UAP). Which assignment(s) should the nurse delegate? (Select all that apply.)
- A. Identify locations of skin lesions on a newly admitted client.
- B. Empty the ostomy bag for a client with a temporary colostomy.
- C. Provide a complete bed bath for a comatose client.
- D. Perform foot care including toenail trimming and heel care.
- E. Give mouth care to an elderly client who has a tracheostomy.
Correct Answer: B,C
Rationale: Emptying an ostomy bag and providing a bed bath are routine tasks within the UAP's scope. Identifying lesions, performing foot care, and giving tracheostomy mouth care require clinical judgment and are RN tasks.
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It is most important to assign which client to a registered nurse rather than a practical nurse (PN)?
- A. One hour after receiving hydromorphone prescribed for every 4 hours PRN use, a client reports severe pain.
- B. Two hours after receiving morphine for acute pain, a client's vital signs are BP 112/60 mm Hg, pulse 88 beats/minute, and respirations 14 breaths/minute.
- C. After ambulating, a postoperative client grimaces and reports incisional pain at a '9 on a ten-point scale'.
- D. The fentanyl transdermal patch for a client with chronic cancer pain needs to be replaced.
Correct Answer: C
Rationale: The postoperative client with severe pain requires immediate RN assessment and intervention due to potential complications. The other clients' needs (PRN medication, stable vitals, routine patch replacement) can be managed by a PN under supervision.
The nurse determines that an IV vesicant chemotherapy infusion is infiltrated. In responding to this finding, which task can the nurse delegate to the unlicensed assistive personnel (UAP)?
- A. Record the patient's pulse volume distal to the IV site every hour.
- B. Reapply cold compresses to the site of the extravasation every hour.
- C. Dispose of the IV tubing after the infusion is discontinued.
- D. Teach the patient about the need to keep the extremity elevated.
Correct Answer: C
Rationale: Disposing of IV tubing is a routine task within the UAP's scope. Recording pulse volume, reapplying compresses, and teaching require clinical judgment, which are RN responsibilities.
In assigning client care to a nurse and a practical nurse (PN), it is most important to assign which client to the nurse?
- A. The client two days post-thyroidectomy and is unable to speak clearly due to laryngeal nerve damage.
- B. The client newly diagnosed with hypothyroidism and who is to receive the first dose of levothyroxine.
- C. The client with diabetes and has an elevated serum glycosylated Hgb (Hgb A1C).
- D. The client exhibiting signs of Addison's crisis after corticosteroids were discontinued.
Correct Answer: A
Rationale: Laryngeal nerve damage post-thyroidectomy risks airway obstruction, requiring RN monitoring. Hypothyroidism, diabetes, and Addison's crisis can be managed by a PN under supervision.
Four clients are scheduled to receive IV infusions, but there are only three intravenous (IV) pumps available. Which prescribed infusion can most safely be administered without an IV infusion pump?
- A. Ceftriaxone in 5% Dextrose in Water prescribed for pneumonia.
- B. Heparin in Normal Saline prescribed for deep vein thrombosis.
- C. Magnesium in Normal Saline prescribed for hypomagnesemia.
- D. Regular insulin in Normal Saline prescribed for ketoacidosis.
Correct Answer: A
Rationale: Ceftriaxone can be safely administered by gravity infusion with nurse monitoring, as its dosing is less sensitive to minor flow rate variations. Heparin, magnesium, and insulin require precise infusion rates due to risks of bleeding, toxicity, or glucose imbalances, necessitating an IV pump.
The nurse determines that an elderly client with pneumonia has a nursing problem of 'altered nutrition, less than body requirements.' Which instruction should the nurse give the unlicensed assistive personnel (UAP) helping with the care of this client?
- A. Offer to assist the client with meal preparation and feeding.
- B. Thicken the client's liquids if aspiration seems likely.
- C. Listen to the client's breath sounds before and after meals.
- D. Assist the client in selecting high protein foods on the menu.
Correct Answer: A
Rationale: Assisting with feeding is within the UAP's scope and addresses the client's nutritional needs. Thickening liquids, listening to breath sounds, and selecting foods require RN judgment.