A nurse delegates a specific intervention to unlicensed assistive personnel (UAP). What implications does this have for the nurse?

The nurse transfers responsibility for completion of the task to the UAP but is accountable for the outcome.

Nurses do not have authority to delegate interventions to a UAP.

The UAP is responsible and accountable for his or her own actions.

Answer and Explanation

The Correct Answer is A

Choice A rationale:

When a nurse delegates a specific intervention to unlicensed assistive personnel (UAP), the nurse transfers the responsibility for completing the task to the UAP. However, the nurse remains accountable for the outcome. Delegation does not absolve the nurse of their accountability; instead, it means that the nurse trusts the UAP to perform the task safely and effectively under their supervision. This approach allows healthcare teams to work collaboratively, improving efficiency and patient care outcomes.

Choice B rationale:

Nurses do have the authority to delegate interventions to UAP, but they must do so responsibly and within the scope of practice. Improper delegation or delegating tasks that UAP are not trained to perform can lead to adverse outcomes and legal consequences.

Choice C rationale:

While the UAP is responsible for their own actions, the nurse remains accountable for the overall patient care. Nurses must ensure that tasks are delegated to competent individuals and provide adequate supervision and guidance. The nurse cannot completely transfer all responsibility to the UAP without being accountable for the outcome.

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Correct Answer is D

Explanation

Choice A rationale:

Applying ankle restraints but leaving the wrists unrestrained is not a balanced approach. Restraints should only be used when necessary and should be applied correctly following the healthcare facility's policies and guidelines. Applying restraints to one part of the body while leaving another unrestrained can lead to injuries and is not a safe practice.

Choice B rationale:

Tying a double knot that is difficult to undo can be dangerous in emergency situations. Restraints should allow for quick release in case of emergencies, ensuring patient safety. Difficult-to-undo knots can delay the removal of restraints, leading to potential harm to the patient.

Choice C rationale:

Tying a slip knot to the side rails of the bed is unsafe and against restraint protocols. Slip knots can tighten when pulled, increasing the risk of injury to the patient. Restraints should be applied to designated areas and never tied to movable parts of the bed or other objects in the room.

Choice D rationale:

Checking on the patient frequently is the most appropriate action when a patient is in restraints. Regular monitoring ensures the patient's safety and well-being, assesses their comfort, and allows for prompt response to any signs of distress or discomfort. Frequent checks also help in preventing complications associated with immobilization, such as pressure ulcers and impaired circulation.

A. Encourage the patient to use an incentive spirometer. B. Auscultate lung sounds bilaterally. C. Ambulate the patient in the hall. D. Position the bed in high fowlers. E. Assess the pulse oximetry.

Correct Answer is ["A","B","D","E"]

Explanation

Choice A rationale:

Encourage the patient to use an incentive spirometer. Rationale: Encouraging the use of an incentive spirometer helps improve lung function and prevent respiratory complications. It promotes deep breathing and prevents atelectasis, especially in patients experiencing dyspnea.

Choice B rationale:

Auscultate lung sounds bilaterally. Rationale: Auscultating lung sounds helps the nurse assess for abnormal breath sounds, such as wheezing or crackles, which can indicate respiratory distress. This assessment is crucial in managing a patient with dyspnea.

Choice C rationale:

Ambulate the patient in the hall. Rationale: Ambulating the patient can worsen dyspnea in some cases, especially if the patient is experiencing severe respiratory distress. Therefore, this intervention may not be appropriate for a patient with dyspnea.

Choice D rationale:

Position the bed in high fowlers. Rationale: Positioning the patient in high fowlers (sitting upright with the head of the bed elevated) helps improve lung expansion and ease breathing. This position maximizes the patient's lung capacity and can provide relief from dyspnea.

Choice E rationale:

Assess the pulse oximetry. Rationale: Monitoring pulse oximetry levels is essential in assessing the patient's oxygen saturation. It helps the nurse determine if the patient is receiving adequate oxygenation, which is crucial in managing dyspnea. A normal oxygen saturation range is typically 95% to 100%.

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A nurse delegates a specific intervention to unlicensed assistive personnel (UAP). What implications does this have for the nurse?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse has placed a patient in restraints and obtained doctor's orders for the restraint.Which action is appropriate for the nurse to conduct for a patient in restraints?

Correct Answer is D

Explanation

A patient is experiencing dyspnea.Which intervention(s) would the nurse implement for the patient? Select all that apply.

Correct Answer is ["A","B","D","E"]

Explanation

The nurse reviews the providers notes that are written in the SOAP format.Which entry represents the "P" portion of the note?

Which intervention would be appropriate for a client with shortness of breath?

The physician has ordered a medication for a patient that is twice the normal dosage of the medication.If the nurse harms a patient by administering the medication, as ordered by the physician, which is true?

The nurse completes an incident report after a patient falls in the hallway while ambulating.The nurse is aware that the primary purpose of this incident report is what?

The nurse is performing discharge teaching for a patient who has had major abdominal surgery. Which statement or question by the nurse would be appropriate?

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Which post is most appropriate for a nursing student to put on a social media platform?