Nokea
Which intervention is appropriate for the nurse to delegate to the unlicensed assistive personnel (UAP) when caring for the female client experiencing acute pain?
- A. Take the pain medication to the room.
- B. Apply an ice pack to the site of pain.
- C. Check on the client 30 minutes after she takes the pain medication.
- D. Observe the client's ability to use the PCA.
Correct Answer: B
Rationale: Applying an ice pack is a non-invasive task within UAP scope. Delivering medication, post-medication checks, and PCA observation require nursing judgment.
You may also like to solve these questions
Which statement explains the nurse's responsibility when obtaining informed consent for the client undergoing a surgical procedure?
- A. The nurse should provide detailed information about the procedure.
- B. The nurse should inform the client of any legal consultation needed.
- C. The nurse should write a list of the risks for postoperative complications.
- D. The nurse should ensure the client is voluntarily giving consent.
Correct Answer: D
Rationale: The nurse ensures voluntary consent, verifying understanding and no coercion, per ethical standards. Detailed information, legal consultation, and risk lists are the HCP’s role.
The postoperative client is transferred from the PACU to the surgical floor. Which action should the nurse implement first?
- A. Apply antiembolism hose to the client.
- B. Attach the drain to 20 cm suction.
- C. Assess the client's vital signs.
- D. Listen to the report from the anesthesiologist.
Correct Answer: C
Rationale: Assessing vital signs establishes a baseline post-PACU, per ABCs. Antiembolism hose, drain attachment, and anesthesiologist report follow.
Which task would be most appropriate for the nurse to delegate to the unlicensed assistive personnel (UAP)?
- A. Complete the preoperative checklist.
- B. Assess the client's preoperative vital signs.
- C. Teach the client about coughing and deep breathing.
- D. Assist the client to remove clothing and jewelry.
Correct Answer: D
Rationale: Removing clothing and jewelry is a non-invasive task within UAP scope. Checklist completion, vital signs, and teaching require nursing judgment.
The circulating nurse observes the surgeon tossing a bloody gauze sponge onto the sterile field. Which action should the circulating nurse implement first?
- A. Include the sponge in the sponge count.
- B. Obtain a new sterile instrument pack.
- C. Tell the surgical technologist about the sponge.
- D. Throw the sponge in the sterile trashcan.
Correct Answer: C
Rationale: Telling the technologist ensures the contaminated sponge is removed from the sterile field, maintaining asepsis. Counting, new instruments, or trashing are secondary or incorrect.
The nurse is caring for a client in acute pain as a result of surgery. Which intervention should the nurse implement?
- A. Administer pain medication as soon as the time frame allows.
- B. Use nonpharmacological methods to replace medications.
- C. Use cryotherapy after heat therapy because it works faster.
- D. Instruct family members to administer medication with the PCA.
Correct Answer: A
Rationale: Administering pain medication PRN within time frames ensures timely relief, per pain management standards. Nonpharmacological methods supplement, cryotherapy timing varies, and family PCA use is unsafe.